Every finding on record at Celebrate SR Living of Moline

Based on record review and interview, the facility failed to use two patient/resident identifiers during medication administration, which resulted in the wrong medication being administered to one resident (R1) of three residents reviewed for medication administration in a total sample of three residents.Findings include:he facility policy, entitled: Standards & Guidelines: Medication Administration, revised 11/22/2024, document: Standard: It will be the standard of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident; 3. Medications should be administered in a timely manner and in accordance with the physician's orders; 7. Use at least two patient or resident identifiers when administering medications. The patient's or resident's room number or physical location is not used as an identifier. Note: At the first encounter, the requirement for two identifiers is appropriate; thereafter, and in any situation of continuing one-on-one care in which the individual providing care knows the patient or resident, one identifier can be facial recognition; 9. Medications should be administered within one (1) hour before or after their prescribed time. 10. After successfully identifying the resident to receive medication administration, the individual administering the medication should ensure that the right medication, right dosage, right time and right method of administration are verified. R1's Electronic Medical Record/EMR document R1's diagnoses to include: Diabetes Mellitus Type II, Squamous Cell Carcinoma of the Skin, End Stage Renal Disease, Dependance on Renal Dialysis, Atherosclerotic Heart Disease [ACHD], Paroxysmal Atrial Fibrillation, Overweight, Dysphagia, Hypertension, Abnormalities of Gait, Muscle Weakness, Hypothyroidism, Hyperlipidemia, Muscle Wasting, Sepsis, and Lack of Coordination. R1's form, entitled PRIVILEGED AND CONFIDENTIAL - NOT PART OF THE MEDICAL RECORD - DO NOT COPY TEST, dated 9/21/25, document: Medications administered include: Gabapentin 300 mg [milligrams], GuaiFENesin ER 600 mg, Norco 5/325 mg [confirmed to be 7.5/325 mg per R2's Medication Administration Record/MAR and V2 interview], Magnesium oxide 420 mg, Melatonin 12 mg [confirmed to be 6 mg per R2's Medication Administration Record/MAR and V2 interview], Metoprolol 50 mg, Multaq 400 mg, Pravastatin 20 mg, trazadone 200 mg; *During a routine medication pass in the dining room, the 300 hall nurse [V3/Registered Nurse] administered [R2's] medication to [R1]. Both residents were initially seated at the same dining room table and both wearing hats. Nurse stated she did not realize the medication error had occurred until she left and returned to the dining room and noticed that [R2] was moved to a different table. Nurse misidentified the resident - Both residents seated near each other and wearing hats - Nurse did not verify using two resident identifiers prior to administration therefore, did not follow the 7 rights and two identifier protocol. R1's Medication Administration Record/MAR document R1's scheduled 6:00 p.m. medications included: Midodrine 10 mg [for blood pressure/BP less than 100/60 in which R1's BP was 90/46], Senna Plus 8.6-50 mg, and Gabapentin 300 mg, were administered 9/21/25.R2's MAR document R2's scheduled 8:00 p.m. medications were: Gabapentin 300 mg [milligrams], GuaiFENesin ER 600 mg, Norco 7.5/325 mg, Magnesium oxide 420 mg, Melatonin 6 mg, Metoprolol 50 mg, Multaq 400 mg, Pravastatin 20 mg, and trazadone 200 mg. On 10/16/25, at 11:45 a.m., V2 (Director of Nurse) confirmed V3 administered R2's medications to R1; and it is V2's expectation that two resident identifiers are used during medication administration and to be administered within the 1 hour before/after scheduled times. On 10/16/2025, at 1:35 PM, V3 confirmed administering R2's 8 PM medication's to R1, saying, I miss identified the gentleman and confused him with someone else.

Based on interview and record review, the facility failed to accurately explain the admission arbitration agreements to residents, or their representatives, in a form or manner that allows them to understand for 12 of 12 residents (R25, R27, R49, R62, R83, R85, R87, R90, R242, R243, R245, R246) reviewed for Arbitration in the sample of 49. Findings Include: The facility's Resident or Resident Representative Arbitration Agreement (undated), documents Whereas it is the intent of the parties that this agreement govern the resolution of any disputes, claims, and any other matters arising out of, or relating to the admissions agreement to fashion a fair and efficient process for resolving any such dispute, claim, or matter. Now, therefore, in consideration of the mutual covenants, terms, and conditions set forth herein, and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows: The arbitrator, and not any federal, state, or local court or agency, shall have exclusive authority to resolve the dispute, claim, or matter relating to the admissions agreement, including the determination of the scope or applicability of this agreement to arbitrate. Waiver of Trial by Jury. The parties understand and fully agree that by entering into this agreement to arbitrate, they are giving up their right to file a lawsuit in court against the other, have a trial by jury, and file an appeal following the issuance of the arbitrator's award, except as applicable law provides for judicial review of arbitration proceedings. The facility's Resident List report, dated 5/5/25, and provided by V1 (Administrator), documents the facility has a total of 12 out of 90 residents who signed a binding arbitration agreement upon admission. This report documents R25, R27, R49, R62, R83, R85, R87, R90, R242, R243, R245, and R246 have signed the agreement. The facility's Electronic Resident Census report documents R25, R27, R49, R62, R83, R85, R87, R90, R242, R243, R245, and R246 were all admitted to the facility after February 2025. R242's Arbitration agreement, dated 3/19/25, documents R242 signed the binding arbitration agreement on 3/19/25, with an effective date of R242's admission on 3/7/25. On 5/7/25 at 9:50 AM, R242 confirmed he has not lived at the facility for long, and stated he isn't sure if he signed his paperwork on admission. R242 stated he does not remember anything about arbitration or signing something related to legal concerns. R242 stated, I don't recall giving up my rights to sue (the facility) or ever agreeing to that. On 5/7/25 at 9:23 AM, V12 (Admissions Coordinator) confirmed she is the one who goes over arbitration agreements with residents and families during admission. V12 stated, I tell them arbitration is where a situation is handled in house before taking it to the next level. I don't explain that they are giving up the right to sue. I tell them they can take it to that next level, but that we just try to settle it in house first. I did not realize the language in the arbitration agreement states they are giving up the right to seek their own council and sue. V12 stated she has been doing the job of admissions and explaining arbitration since February 2025. V12 stated the prior admissions employee no longer works in the facility, and V12 is unaware of how it was explained to residents who admitted prior to her taking over, three months ago.

Based on interview and record review, the facility failed to provide a written notice of transfer and a copy of the facility's bed hold policy upon a resident's transfer to a local hospital for three of four residents (R13, R65 and R79) reviewed for hospitalization s in the sample of 49. Findings include: 1. R13's Progress Note (dated 07/10/24 and timed 11:15 AM) documents: Resident (R13) seen by wound nurse, referred to ID (Infectious Disease) who stated to send resident to ED (Emergency Department). Family contacted, voicemail left. R13's Progress Note (dated 07/10/24 and timed 08:39 PM) documents: Resident has been admitted to (local hospital). R13's medical record does not contain documentation that a written notice of transfer or a copy of the facility's bed hold policy was provided to R13 and/or her representative upon her 07/10/24 transfer to the hospital. On 05/06/25 at 02:20 PM, V2 (Director of Nursing) stated she could not provide documentation indicating a written notice of transfer or the facility's bed hold policy was provided upon R13's 07/10/24 transfer to the hospital. 2. R65's electronic census documents R65 was hospitalized on [DATE]. R65's Progress Note (dated 12/15/24 and timed 02:42 PM) documents: Resident (R65) noted in room with some confusion, lethargic, clammy, resident unable to voice needs at this time. Emergency transport contacted. (Blood pressure) 106/62, (Pulse) 135, (Temperature) 98.7, (Pulse Oximetry) 91%. Resident's son contacted and notified, resident being transported to (local hospital). R65's Progress Note (dated 12/15/24 and timed 08:49 PM) documents: This nurse contacted (local hospital) to get an update on patient (R65). Patient has urosepsis and an acute kidney injury. Patient is getting ready to be transferred to (Regional hospital). R65's medical record does not contain documentation that a written notice of transfer or a copy of the facility's bed hold policy was provided to R65 and/or his representative upon his 12/15/24 transfer to the hospital. On 05/06/25 at 02:20 PM, V2 (Director of Nursing) stated she could not provide documentation indicating a written notice of transfer or the facility's bed hold policy was provided upon R65's 12/15/24 transfer to the hospital. 38396 3. R79's Nursing Progress Notes, dated 4/14/2025, documents at 10:19 AM, R79 was transferred to the local emergency room after suffering a fall. R79's current electronic medical record does not document a bed hold notice or notice of hospital transfer was provided to R79 or her representative at the time of transfer to the hospital. On 5/6/25 at 2:20 PM, V2 (Director of Nursing) stated she could not provide documentation a written notice of transfer or the facility's bed hold notice was provided upon R79's 4/14/25 transfer to the hospital.

Based on observation, interview, and record review, facility staff failed to recognize the potential adverse effects of abruptly stopping a medication without tapering for one of five residents (R73), reviewed for unnecessary medications, in a sample of 49. FINDINGS INCLUDE: The facility policy, Standards and Guidelines: Medication Errors, dated (revised 3/27/2021), documents, It will be the standard of this facility that the staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. The staff and practitioner shall strive to minimize adverse consequences by: Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration and monitoring of the medication. The 2024 American Association of Psychiatric Pharmacists Medication Fact Sheet for Escitalopram documents, Do not stop taking Escitalopram, even when you feel better. With input from you, your health care provider will assess how long you will need to take the medicine. Missing doses of Escitalopram may increase your risk for relapse in your symptoms. Stopping Escitalopram abruptly may result in one or more of the following withdrawal symptoms: irritability, nausea, feeling dizzy, vomiting, nightmares, headache, and/or paresthesia (prickling, tingling sensation on the skin). R73's facility Admission Record documents R73 was admitted to the facility on [DATE], with the following diagnoses: Peripheral Vascular Disease, Abdominal Aortic Aneurysm, Paroxysmal Atrial Fibrillation, Chronic Combined Systolic and Diastolic Heart Failure, Major Depressive Disorder, Anxiety Disorder, Hypertensive Urgency, Essential Hypertension, and Chronic Kidney Disease. R73's Follow Up Psychiatric Assessment, dated 4/17/2025, documents, (R73) has a history of Major Depressive Disorder and Anxiety seen for follow up evaluation. Current Psychiatric Medications: Escitalopram, Buspirone and Lorazepam. Assessment: (R73) is calm, cooperative and sitting on her bed during the evaluation. (R73) denies depression and anxiety. Staff reports no change in mood but states resident is anxious without (medications). Treatment Plan: Continue Buspirone twice daily for anxiety, Lorazepam for anxiety and Escitalopram for depression. R73's April 22, 2025 Medication Administration Record includes the following physician orders: Escitalopram Oxalate (Selective Serotonin Reuptake Inhibitor) 5 MG (Milligrams) daily for Agitation and Anxiety related to Major Depressive Disorder; Lorazepam (Benzodiazepine) 0.5 MG at bedtime related to Anxiety Disorder; Nifedipine Extended Release (Calcium Channel Blocker) 90 MG daily for Hypertension and Metoprolol Succinate Extended Release (Beta Blocker) 25 MG twice daily for Hypertension. R73's After Visit Summary, dated 4/23/25, from the local Renal Clinic documents, Today's medication changes: Stop taking Amiodarone 200 MG, Escitalopram, Lorazepam, Metoprolol, Nifedipine and Potassium Chloride. On 5/05/25 at 10:16 A.M., R73 was sitting at side of the bed, attempting to pull up her pants. R73 was crying and visibly distressed. When asked what was wrong, R73 stated, Everything. Everything is all wrong. R73 was unwilling to say anything else when prompted. V6/Licensed Practical Nurse (LPN) was at R73's bedside, and stated some of R73's medications were changed recently, and R73 just hasn't been herself. R73's Nursing Progress Notes, dated 5/5/2025 at 12:36 PM, documents, Renal (Clinic) d/c (discontinued) (R73's) Lexapro (Escitalopram) and lorazepam on 04/23/25. Since then (R73) has been tearful and upset. Called Renal (Clinic) to find out why these meds (medications) were discontinued on (05/02/2025) with no call back. Called Renal (Clinic) back today. Nurse states that she will talk with the doctor and call facility back with response. Facility number clarified. R73's Nursing Progress Notes, dated 5/5/2025 at 2:11 PM, documents, Renal (Clinic) called back stating that d/c (R73's) meds was a mistake. Psych (Psychiatric) doctor gave order to reinstate both Lexapro (Escitalopram) and lorazepam. POA (Power Of Attorney) notified. Will continue to monitor mood. On 5/06/25 at 1:41 PM, V7/Certified Nursing Assistant (CNA) stated she often works with R73. V7 stated R73 has a history since admission of being tearful and distraught due to her family moving R73 to the facility and selling her home and belongings. V7 stated R73 has been more tearful and distraught in the past week or so. On 5/06/25 at 2:10 PM, V10/Licensed Practical Nurse (LPN) stated she was the nurse that was present when R73 returned from the doctor's appointment with orders to discontinue Amiodarone (Class 3 Antiarrhythmic); Escitalopram (Selective Serotonin Reuptake Inhibitor); Lorazepam (Benzodiazepine); Metoprolol (Beta Blocker); Nifedipine (Calcium Channel Blocker); and Potassium Chloride (Supplement). V10/LPN states she didn't question the order, nor did she notify R73's medical doctor prior to discontinuing the medications. On 5/06/25 at 2:20 PM,V11/R73's Physician stated, I was not aware that (R73's) medications had been stopped. No one notified me. I would not have agreed to stopping those medications without tapering them. That is very dangerous and could cause serious side effects.

Based on interview, observation, and record review, the facility failed to implement Enhanced Barrier Precautions prior to administering cares for two of six residents (R13 and R65) reviewed for Transmission Based Precautions in the sample of 49. Findings include: The facility's Enhanced Barrier Precautions Policy (dated 04/05/24) documents the following: (Facility) will implement Enhanced Barrier Precautions (EBP) to protect residents, staff and visitors by reducing the transmission of MDROs (multi-drug resistant organisms). EBP will be used for residents with specific risk factors, as outlined by the Centers for Disease Control and Prevention, (State Agency), and relevant local health authorities. These precautions will be applied consistently across the facility as part of routine care. This same policy documents, Procedures: Identification of residents for Enhanced Barrier Precautions; EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with the following: Wounds or indwelling medical devices, regardless of MDRO colonization status; Infection or colonization with an MDRO. This policy also documents: Gowns and gloves will be used by all healthcare personnel when performing high-contact resident care activities. These precautions must be used when providing care related to: Dressing, bathing and hygiene assistance; Wound care, handling bandages and dressings; Caring for devices such as urinary catheters or central lines; Moving or transferring residents in/out of bed; Cleaning rooms or touching frequently touched surfaces (bed rails, Intravenous poles, etc.). Staff should don PPE (personal protective equipment) before resident contact and discard PPE upon leaving the resident's care area, followed by hand hygiene. 1. R13's current Physician's Orders document the following order: Enhanced Barrier Precautions. Diagnosis: Wound. On 05/05/25 at 11:05 AM, a sign indicating Enhance Barrier Precautions currently in place was posted on R13's door, and a bin containing personal protective equipment was sitting in the hallway near the entrance to R13's room. R13 was sitting in a wheelchair next to her bed and was wearing an orthopedic shoe on her right foot. R13 stated, I've had a couple of my toes amputated, and then explained that she currently receives a daily dressing change to an open area on her right foot between her first toe and second toe. On 05/07/25 at 09:45 AM, R13 was sitting in a wheelchair in her room near her bed. R13 was wearing an orthopedic boot on her right foot. V9 (Licensed Practical Nurse/Wound Nurse) entered R13's room to perform wound care and a dressing change to R13's right foot wound. V9 applied gloves, removed R13's orthopedic boot and sock, and a dressing was in place on R13's right foot. V9 removed R13's current dressing, and an open, oval-shaped wound measuring approximately 2.5 centimeters by 1 centimeter was present between R13's right first toe and second toe. V9 cleansed R13's wound with saline, applied betadine to the open area, covered the wound with a betadine-soaked gauze and secured it with a thin gauze wrap and tape. Once cares were completed, V9 reapplied R13's sock and orthopedic shoe. V9 did not wear a gown while performing R13's cares. On 05/07/25 at 09:55 AM, V9 confirmed R13 is currently in Enhanced Barrier Precautions, and verified she did not wear a gown while performing R13's wound care. 2. R65's current Physician's Orders document the following order: Enhanced Barrier Precautions. Diagnosis: Indwelling Catheter. On 05/05/25 at 11:15 AM, a sign indicating Enhanced Barrier Precautions currently in place was posted on R65's door and a bin containing personal protective equipment was sitting in the hallway near the entrance to R65's room. R65 was lying in bed with his eyes closed at this time. An indwelling urinary catheter drainage bag was secured to the lower aspect of R65's bed. R65 stated he has had an indwelling urinary catheter in place, for a while. On 05/07/25 at 09:30 AM, R65 was lying in bed with the head of his bed elevated to approximately 45 degrees. R65 was wearing a gown and was covered with a sheet from the waist down. An indwelling urinary drainage bag was attached to the lower aspect of R65's bed, and the drainage bag's tubing was draining yellow urine with sediment present. V8 (Certified Nursing Assistant) entered R65's room at this time to provide indwelling urinary catheter care. V8 applied gloves, approached R65, and uncovered him. R65's indwelling urinary catheter was in place and was secured to his right leg with a securement device. V8 cleansed R65's indwelling urinary catheter with adult incontinence wipes. Once cares were completed, V8 assisted R65 to reposition in bed, and then covered him with a sheet. V8 did not wear a gown while performing R65's indwelling catheter care. On 05/07/25 at 09:40 AM, V8 confirmed R65 is currently in Enhanced Barrier Precautions for his indwelling urinary catheter, and stated she should have worn a gown while performing his indwelling urinary catheter care.

Based on observation, interview and record review the facility failed to comprehensively assess pain and effectively manage pain for one resident (R67) of three residents be reviewed for pain. This failure has resulted in ineffective pain management and ongoing expression of moderate to severe pain by R67. Findings include: The Facility's Pain Management Policy dated 3/26/21 documents: It will be the standard of this facility to screen residents and attempt to provide effective pain and comfort management. Residents may additionally be screened for pain quarterly, annually, upon change of condition or upon resident report of new pain or newly observed non-verbal signs and symptoms of potential pain. On-going monitoring of residents receiving interventions should be completed in the clinical record, as indicated. Implement/update a person-centered care plan of care related to pain management as is appropriate. R67's Hospital Discharge Note dated 12/31/23 indicates R67 reported generalized and buttock pain score 10/10 (scale 0 = no pain; 1 to 3 = mild pain; 4 to 7 = moderate pain; and 8 or above is severe pain) five times prior to receiving Acetaminophen 650mg (milligrams) and reported generalized and buttock pain of 6/10 three times and 10/10 twice prior to receiving Tramadol (analgesic). Follow up pain relief/response to administration of Tramadol was documented as 1 to 4/10 indicating effectiveness of medication. R67's Admission Nursing Note Pain Screen dated 12/31/23 at 3:19pm indicates R67 indicated she was experiencing generalized pain 7/10. Note indicates R67's pain is relieved by medication management and repositioning. R67's Physician Note dated 1/2/24 indicates R67 was previously bedridden at home due to Arthritis. Note indicates R67 has arthritic changes in her hands, knees, and feet. Note indicates R67 reports severe pain with turning when wound care is done and reports the pain is in her legs. Note indicates R67 reports pain is 10/10 all over in all joints. R67's Physician Note dated 2/7/24 indicates R67 has a Stage 4 sacral pressure wound, full thickness. R67's Physician Note dated 2/16/24 indicates R67 states that she continues to have pain with any kind of transitioning or rotation in bed and that R67's mood is fine when she is otherwise lying still related to her arthritis. Note indicates (R67) has pretty significant pains and discomfort of the large coccyx wound. On 3/13/24 at 9:35am R67 was turned onto her side to receive sacral wound care. R67 was distressed with facial grimacing, stiffening, guarding, and reporting pain throughout her lower body. While on her side during wound care R67 continued to intermittently complain of pain. R67 cried out and whimpered when V4 (Wound Nurse) removed the wound vac sponge from inside R67's sacral wound, cleaned inside R67's sacral wound and inserted a new wound vac sponge into R67's sacral wound. V4 attempted to console R67 during the wound treatment to which R67 replied No, you don't know. It's horrible. At that time V4 reminded R67 that she had received a Norco (opioid) earlier in the morning (7:40am) to help with the pain. R67 replied that the pain was still there. On 3/13/24 at 1:40pm R67 stated I have chronic arthritis everywhere, particularly my knees and feet. My knees are throbbing right now. I'm up all night sometimes, I can't sleep because I'm uncomfortable. Then I sleep on/off during the day because I'm tired from not sleeping at night. The worse pain is in my coccyx, then knees and feet. Even the slightest movement is severe pain. I used to ask for the Norco in the evening, but I became really constipated. It was like having a baby - really painful also causing pressure and pain in my coccyx. While R67 described her pain she became tearful and expressed how she tries not to complain. R67 stated her pain was 9 or 10 out of 10 during wound treatments stating, It feels like they are pulling my skin off. R67 stated the Norco she received at 7:40am (prior to wound care) did not really help much and barely takes the edge off. R67's current Physician Order Summary Report indicates R67 has orders for: Hydrocodone-Acetaminophen 5-325mg (milligrams), Give one tablet every day shift for pain - to be given one half hour prior to wound treatment. Hydrocodone-Acetaminophen 5-325mg every six hours as needed for moderate pain. Acetaminophen 650mg every six hours as needed for general discomfort. R67's MAR (Medication Administration Record) dated 2/1/24 to 2/29/24 and 3/1/24 to 3/13/24 indicates R67 received Hydrocodone-Acetaminophen 5-325mg for pain prior to wound care. MARs indicate R67 reported pain level 8/10 seven times, 9/10 twelve times and 10/10 seven times prior to administration of Hydrocodone prior to the wound care. R67's MAR dated 2/1/24 to 2/29/24 indicates R67 received as needed Hydrocodone-Acetaminophen 5-325mg on 2/1, 2/3, 2/4, 2/5, 2/6 and 2/7/24 in the evenings for reports of pain 6 - 8/10. R67's MARs indicate R67 only received as needed Acetaminophen 650mg on 2/9/24 for pain level of 4/10 and on 3/4/24 for pain level of 9/10. R67's MARs also indicate R67 is monitored for pain every shift and scored zero (no pain) every shift on every day from 2/1/24 to 3/13/24 even though R67 had expressed pain and received pain medication on the above dates listed. Weekly Wound Progress Notes dated 2/15/24, 2/22/24 and 2/29/24 indicates R67 reported pain of 10/10 during sacral wound care on all the above dates. Notes dated 2/22/24 and 2/29/24 indicate R67 had the following non-verbal indicators of pain: Negative vocalizations (i.e., moaning, groaning, crying, calling out) Facial expressions (i.e., grimacing, frown, sad) Body language (i.e., tensed, distressed, pacing, fists clenched, striking out, knees pulled up, guarding) consolability [sic] (i.e., distracted, unable to console). R67's Weekly Wound Progress Note dated 3/6/24 indicates R67 reported pain level of 5/10 during wound care and exhibited negative vocalizations. On 3/14/24 at 1:00pm V2 (Director of Nursing/DON) stated she could not explain why R67's every shift pain score was zero yet R67 reported pain level of 10/10 during wound care and pain score prior to wound treatment was usually 6-10. V2 also stated there was no further assessment of R67's pain after reporting pain 10/10 during wound care. R67's NP (Nurse Practitioner) note dated 3/13/24 indicates R67 has osteomyelitis of coccyx and Stage 4 sacral wound. Note indicates R67 is seen in her room as she has reported uncontrollable pain. Note indicates she has been offered additional Norco but has refused due to fear of constipation. Discussed a long-acting Tylenol for pain and R67 is agreeable to a trial of standard release Tylenol scheduled every 8 hours. Note indicates an additional Hydrocodone (narcotic) with Acetaminophen in the evening for severe pain if she needs and if she allows it to be given. Note indicates additional options for constipation were also discussed. Note indicates R67 has a history of refusing narcotic pain medications. R67's Care Plan (date initiated 12/31/23) documents Potential/Actual pain related to Arthritis. Interventions include Monitor and Report signs and symptoms of pain, worsening of pain; notify physician if resident does not state/demonstrate relief or reduction of pain with current pain management regimen. This same care plan does not include history of R67 refusing pain medications, locations/characteristics of pain or non-pharmacologic interventions to assist in alleviating pain. On 3/14/24 at 1:30pm V2 (DON) stated R67 has had a history of refusing pain medications. V2 was unable to provide a comprehensive assessment of R67's pain (after admission assessment) and/or documentation/assessments of R67's refusal of pain medications offered. On 3/14/24 at 1:30pm V9 (Nurse Practitioner) stated she was unaware R67 had been taking (as needed) Norco every evening and abruptly stopped (on 2/8/24) due to becoming constipated. V9 stated that as of yesterday R67 has orders for scheduled Tylenol and an additional Hydrocodone as well as review of bowel medications to address R67's constipation.

Based on record review and interview the facility failed to complete an Identified Offender care plan for one resident (R85) of five residents reviewed for Identified Offender Status in a total sample of thirty-three. Findings Include: The Facility's Baseline Care Plan Policy dated 12/06/2022 documents The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. The Facility's Identified Offender Procedure/Protocol document Complete an Identified Offender/Behavior Risk Assessment, if one has not already been completed and complete an IO (Identified Offender) Care Plan as soon as possible (within 36 hours is suggested.) Make sure to communicate any high-risk convictions and concerns to Administration/Director of Nursing to address safety issues and risk management. R85's Criminal History Report documents the following convictions: 08/09/2018 Criminal Trespass to Residence, 12/17/2018 Criminal Trespass to Residence, 2/10/2020 Criminal Trespass to Residence, 1/21/2014 Aggravated DUI (Driving under the Influences), 2/27/13 DUI/Alcohol, 5/22/2013 DUI Alcohol/Drugs, 10/16/24 DUI Alcohol/Drugs, 7/14/2015 Aggravated DUI, 11/7/2012 Knowingly Damage Property, 11/7/2012 Resist Peace Officer, 9/8/12 Knowingly Damage Property, 9/10/2012 Knowingly Damage Property, 11/7/2012 Criminal Damage to Property, 1/23/2012 2 counts of Resist Peace Officer, 11/21/2011 Resist Peace Officer, 1/23/2012 Resist Peace Officer, 10/30/2011 Resist Peace Officer, 1/23/2012 Resist Peace Officer, 9/21/2011 Retail Theft/Merchandise less than $150, 8/11/21 Retail Theft, 9/21/11 Retail Theft, 12/29/10 Criminal Trespass to land and Domestic Battery/Physical Contact, 11/27/2010 Criminal Trespass to Building, 11/29/2010 Criminal Trespass to Land and 12/27/2010 Criminal Trespass to Land. R85's Criminal History Analysis Security Recommendation Report completed by the State Police on 10/23/23 documents The resident requires closer supervision and more frequent observation than standard or routine for most residents in an open facility. Regular monitoring should be attentive to behavioral changes that may signal a need for closer observation or sustained visual monitoring on a time-limited basis. His compliance with psychiatric/medical treatment and abstinence from alcohol/drug use should be closely monitored. In view of his alcohol/drug abuse history and extensive criminal history, a moderate risk supervision status is recommended. R85's current Care Plan dated 01/12/24 shows an admitted [DATE] and does not include any information about R85's identified offender status, or how frequently R85 should be monitored. On 3/13/24 at 1:50 PM V1 (Administrator) confirmed that there was no mention of R85's criminal history in his care plan and there should be.

Facility failures resulted in two deficient practices. A. Based on observation, interview and record review the Facility failed to comprehensively assess a facial wound for one resident (R75) of three residents reviewed for wounds in the sample of 33. B. Based on observation, interview and record review the Facility failed to complete scheduled daily Diabetic Foot Ulcer treatments per Physician orders for one resident (R34) of five residents reviewed for Skin Issues in the sample of 33. Findings include: A. The Facility's Skin and Wound Policy dated 3/27/21 documents: Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. The presence of skin impairment should be denoted on the person-centered plan of care. Residents with pressure injuries or other wounds requiring measurements should also have weekly documentation in the clinical record reflecting the condition of the wounds and any changes that take place. R75's Hospital History and Physical Report dated 10/15/22 indicates R75 has a lesion around right orbital area suggestive of skin cancer. R75's Admission Nursing Note dated 10/20/22 indicates R75 has Right has blackened area around orbit of eye. Skin missing above eye. States it's been like this for [AGE] years; got infected and scratches area. R75's Nurse Note dated 2/29/24 at 1:44pm indicates R75 is on antibiotics for infection to right eye; yellow pus noted to be coming from area surrounding eye. The note indicates R75 has a history of skin impairment to this eye and surrounding tissue. On 3/12/24 at 2:39pm R75 was seen in his room resting on the bed. At that time R75 was noted to have a scaly, red, scabbed area over entire right eye, extending over bridge of nose and surrounding areas. At that time R75 stated he is only able to see about 75% from his right eye. On 3/12/24 at 2:45pm V2 (Director of Nursing/DON) stated that R75 has never been officially diagnosed but has probable cancer of the eye and surrounding tissue. V2 stated R75's eye started weeping pus-like drainage and was recently put on antibiotics. R75's Current Physician Order Summary Report/Diagnoses includes Ischemic Optic Neuropathy. Diagnosis list does not include cancer of R75's right eye or skin cancer of surrounding tissues. Order Report also indicates staff are to apply [NAME] Petrolatum to area around eye wound topically every eight hours as needed for skin care. R75's Care Plan indicates R75 has impaired visual function related to visually impaired due to blindness in right eye secondary to possible ocular cancer. Care Plan also indicates has a skin impairment right forearm skin tear but does not include facial wound across R75's right eye. On 3/14/24 at 9:00am V2 (DON) stated Our weekly wound assessments, only ask if there's a new problem - if stays the same - no further assessment. V2 stated that staff only document if there are changes. Current non-pressure wound logs do not include monitoring of R75's right eye/face wound. No further descriptions/assessments of R75's right eye/orbital area were found or presented after admission skin assessment of 10/20/22. 33975 B. Facility Standard and Guideline Wound Care Policy, revised 3/27/21, documents: it will be the standard of the this Facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment; wound care procedures and treatments should be performed according to Physician orders; wound care treatment should maintain proper technique, as indicated by the type of wound and Physician orders; document in the clinical record when treatments are performed; and contact the Physician for additional order changes as is appropriate or to notify of skin condition changes. Facility Standards and Guidelines Physician/Non-Physician Practitioner Order Policy, revised 10/24/22, documents it will be the practice of this Facility to honor Physician/Licensed Independent Practitioner orders in the following ways (Telephone Orders, Orders received by Non Physician Practitioner /Nurse Practitioner/Physician Assistant, Faxed Orders and Electronic Orders). The Facility Skin Log, dated 3/6/24, documents Diabetic Foot Ulcers to R34's Left First Toe and Left Second Toe and an Arterial wound to R34's Right Heel. R34's Physician Order Sheet/POS, dated 3/13/24, documents R34's diagnoses including Peripheral Vascular Disease, Hyperlipidemia, Palliative Care, Diabetes Mellitus due to underlying condition with Foot Ulcer, Severe Protein-Calorie Malnutrition, Diabetes Mellitus due to underlying condition with Diabetic Chronic Kidney Disease, Hypertension, Dysphagia, Chronic Systolic Heart Failure, Anxiety Disorder, Anemia, Diabetes Mellitus due to underlying condition with Diabetic Polyneuropathy, Vitamin D Deficiency, Local Infection of Skin and Subcutaneous Tissue, Muscle Wasting and Atrophy and Lymphedema. V7's (Wound Doctor) Progress Notes, dated 3/6/24, document: Diabetic Wounds to R34's Left First Toe (2.2 centimeters/cm by 1.2 cm by 0.4 cm and 100 percent black necrotic tissue/eschar); Arterial Wound of the Right Heel (Full Thickness, no measurements) and treatment of a topical medication (Betadine) and cover with dry dressing (Telfa and Gauze Kerlix); and Diabetic Wound of the Left Second Toe (Full Thickness) and treatment of a topical treatment (Betadine and Calcium Alginate) and cover with a dry Dressing (Gauze Island with Border or Band-Aid). R34's Physician Order Sheet, dated 3/13/24, documents the following orders: apply topical treatment (Betadine) to Left Heel Wound and Left Pinky Toe every day shift; apply topical treatment (Betadine) to wounds on Right Ankle, Right Foot, Right Medial Foot and Right Calf, cover with dry dressing (Telfa and wrap in Kerlix) every day shift; and apply topical treatment (Betadine) to Right Great Toe, Right Second Toe and Right Third Toe every day shift. R34's Physician Orders did not document a treatment to R34's Left Second Toe or Right Heel. On 3/13/24 at 10:46 am, V4 (Licensed Practical Nurse/Restorative Nurse) was performing wound care to R34. R34's Left Pinky Toe, Left Third Toe and Left Fourth Toe had on an undated, dry gauze dressing. V4 attempted to remove approximately three gauze dressings (measuring four inches by four inches) from R34's Toes and V4 was unable to, due to the gauze dressing being adhered to R34's Toes. V4 then saturated, with Normal Saline, the gauze dressing and attempted to remove the gauze, and was unsuccessful. V4 made two additional unsuccessful attempts, with the Normal Saline to remove the gauze dressing. On the fourth attempt, V4 pulled the gauze dressing from all five of R34's Toes, pulling and removing some of R34's skin, exposing the open areas. R34's Right Heel dressing was dated 3/11/24. On 3/13/24 at 12:16 pm, V8 (Licensed Practical Nurse/LPN) stated, I worked on 3/12/24 and even though I signed the treatments off on the TAR (Treatment Administration Record), I could not find the Betadine, so I did not do (R34's) treatment that day. On 3/13/24 at 10:51 am, V4 (Licensed Practical Nurse/Restorative Nurse) stated, That gauze dressing should not be on (R34's) Left Toes. The treatment should be Betadine and open to air. Whoever did this treatment should have not covered these areas with gauze because it is sticking to (R34's) toes and pulling his skin off. Also, (R34's) Right Foot and Heel dressing looks like it did not get changed on 3/12/24, because the dressing is still dated 3/11/24, and that should be changed every day.

Based on observation, interview, and record review, the facility failed to ensure hand hygiene after glove use was conducted during wound care for one resident (R51) and failed to follow a Physician ordered pressure ulcer treatment for one resident (R34) of five residents reviewed for pressure ulcers in a sample of 33. Findings include: 1. The facility's Wound Care policy, revised 3/27/21, documents 7. Wound care treatment should maintain proper technique, as is indicated by the type of wound and physician orders. The facility's Personal Protective Equipment (PPE) Use policy, revised 3/30/21, documents Standard: It will be the standard of this facility that staff appropriately utilize personal protective equipment (PPE) for the prevention of transmission of potentially infectious organisms. Guidelines: 1. Apply clean non-sterile gloves when touching blood, body fluids, secretions, excretions, contaminated items, mucous membranes, and non-intact skin. Don clean gloves between tasks and procedures on the same resident after contact with blood, body fluids, secretions, excretions. remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. Wash and or sanitize hands after the removal of gloves. On 3/13/24 at 10:12am, R51 sat in a reclining chair with bilateral heel protectors on. V4 (Licensed Practical Nurse/LPN/ Restorative Nurse) prepared supplies for R51's wound treatment. V4 washed her hands then donned gloves. V4 removed R51's dressing and Calcium alginate then removed her gloves. Without washing or sanitizing hands V4 donned new gloves. V4 noted that R51's small pea sized open area to R51's left lateral heel had a small amount of drainage. V4 cleansed R51's wound with normal saline soaked gauze. V4 removed her gloves then without washing or sanitizing her hands V4 donned new gloves. V4 dried R51's wound area with dry gauze then applied Calcium alginate with silver and bordered foam dressing. With the same soiled gloves, V4 put R5's gripper socks and bilateral heel protectors back on. R51's Wound Evaluation & Management Summary, dated 3/6/24, documents R51 has a Stage 4 Pressure Wound of the left, lateral heel. On 3/13/24, at 1:15pm, V4 stated that V4 normally washes her hands after glove changes if going from dirty to clean. V4 stated I should have washed my hands after I took the dressing off and saw the drainage and after each glove change. 33975 2. Facility Standard and Guideline Wound Care Policy, revised 3/27/21, documents: it will be the standard of the this Facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment; wound care procedures and treatments should be performed according to Physician orders; document in the clinical record when treatments are performed; and contact the Physician for additional order changes as is appropriate or to notify of skin condition changes. Facility Standards and Guidelines Physician/Non-Physician Practitioner Order Policy, revised 10/24/22, documents it will be the practice of this Facility to honor Physician/Licensed Independent Practitioner orders in the following ways (Telephone Orders, Orders received by Non-Physician Practitioner /Nurse Practitioner/Physician Assistant, Faxed Orders and Electronic Orders). The Facility Pressure Ulcer Log/Monthly Wound Log, dated 3/24, documents R34's Pressure Ulcers to R34's Right Ankle (Stage Four/Stage IV), Right Medial Foot (Suspected Deep Tissues Injury/SDTI), Right Lateral Food (Unstageable), Right Calf (Unstageable) and Left Lateral Foot (Deep Tissue Injury). R34's Physician Order Sheet/POS, dated 3/13/24, documents R34's diagnoses including Peripheral Vascular Disease, Hyperlipidemia, Palliative Care, Diabetes Mellitus due to underlying condition with Foot Ulcer, Severe Protein-Calorie Malnutrition, Diabetes Mellitus due to underlying condition with Diabetic Chronic Kidney Disease, Hypertension, Dysphagia, Chronic Systolic Heart Failure, Anxiety Disorder, Anemia, Diabetes Mellitus due to underlying condition with Diabetic Polyneuropathy, Vitamin D Deficiency, Local Infection of Skin and Subcutaneous Tissue, Muscle Wasting and Atrophy and Lymphedema. V7's (Wound Doctor) Progress Notes, dated 3/6/24, document: R34's Pressure Ulcers: Stage Four/Stage IV Pressure Wound of the Right Ankle (Full Thickness, 3.5 centimeters/cm by 3.2 cm by 0.2 cm, black necrotic tissue/eschar); Unstageable Pressure Ulcer due to Necrosis of the Right Lateral Foot (Full Thickness, 17.0 cm by 8.0 cm by 0.4 cm, black necrotic tissue/eschar); Unstageable Pressure Ulcer/Deep Tissue Injury/DTI of the Right Medial Foot (Undetermined Thickness, 0.8 cm by 0.8 cm by not measurable, intact with purple/maroon discoloration); and Unstageable Pressure Ulcer of the Right Calf (12.8 cm by 4.5 cm by 0.2 cm, forty percent/40% eschar). V7's Progress Notes document a daily dressing change to all of R34's Pressure Ulcers (Betadine, nonstick gauze pad, and gauze wrap). R34's Physician Order Sheet, dated 3/13/24, documents the following orders: apply topical treatment (Betadine) to wounds on Right Ankle, Right Foot, Right Medial Foot and Right Calf, cover with dry dressing (nonstick gauze pad and wrap in gauze) every day shift. On 3/13/24 at 10:46 am, V4 (Licensed Practical Nurse/Restorative Nurse) was performing wound care to R34. R34's Right Foot and Right Lower Extremity had an intact dressing (gauze wrap and nonstick gauze pad) that was dated 3/11/24 with the signature/initials of V3 (Assistant Director of Nursing/ADON). The dry dressing had a moderate amount of dry red exudate/blood/drainage. On 3/13/24 at 10:51 am, V4 (Licensed Practical Nurse/Restorative Nurse) stated, (R34's) Right Foot and Heel dressing looks like it did not get changed on 3/12/24, because the dressing is still dated 3/11/24. On 3/13/24 at 12:16 pm, V8 (Licensed Practical Nurse/LPN) stated, I worked on 3/12/24 and took care of (R34), and I could not find the Betadine, so I did not do (R34's) treatment that day, but I did sign the treatments off anyway, as completed on the TAR (Treatment Administration Record). On 3/13/24 at 12:25 pm, V3 (Assistant Director of Nursing/ADON) stated, I did (R34's) treatments on 3/11/24. It looks like (R34's) treatments have not been completed since 3/11/24, and I am not sure why gauze was put on (R34's) Left Toes. V3 verified that V8 (LPN) signed R34's completed treatments out on the TAR, even though the treatments were not completed.

Based on observation, interview and record review, the facility failed to notify the physician for an identified sign of infection in a pressure ulcer for one resident (R7). The facility also failed to identify a pressure ulcer and notify the physician for one resident (R18). These failures effected two out of four residents reviewed for pressure ulcer in a sample of 47. This failure caused a delay in treatment resulting in R7 being admitted to the Intensive Care Unit (ICU) for septic shock due to an infection in his stage IV right hip pressure ulcer. Findings include: The facility's Standards and Guidelines: SG Wound Care policy dated 3/27/21, documents 11. Document the progression of the wound being treated. Such observations should be items size, staging (if applicable), odors, exudate, tunneling, etiology etc. 12. Contact the physician for additional order changes as appropriated or to notify of skin condition changes or refusals of care. 1. On 02/14/23 at 12:14 PM, V4 (Licensed Practical Nurse/LPN), stated (R7) isn't here, he had an appointment this morning at the wound clinic, but he's not coming back. I was just informed the wound clinic sent him to the emergency room (ER) due to an elevated heart rate, low blood pressure and fever. They think he may have sepsis. R7's wound assessment dated [DATE] documents Left hip pressure ulcer stage IV and Right hip pressure ulcer stage IV. R7's physician order sheet dated 2/6/23 documents Change wound vacuum to left and right ischial ulcers using black foam at 175 millimeters of mercury (mmhg) for left 125 mmhg for right continuous changing three times a week and utilize xeroform, with a bordered gauze changing three times per week to his left lower extremity. (Wound solution, a mixture of sodium hypochlorite (0.4% to 0.5%) and boric acid (4%) diluted in water) soak for five to ten minutes with dressing changes. Cleansing all wounds with normal saline or wound wash of choice with dressing changes. 2/13/23 12:16pm R7's medical record documents Late Entry: Note Text: Wound vacuum to right and left hip changed per orders. Right hip noted to have foul smell and necrotic tissue. Resident to follow up with wound clinic on 2/14/23. Resident denies any pain at this time. Will continue to monitor. V29's (Medical Director) physician visit note dated 2/7/23 document's Of note, (R7) also reportedly had a seizure in the setting of acute infection in October. Of note, upon further review of his chart, it appears that he was admitted locally in October 2022 with sepsis and seizure like activity requiring intubation for airway protection. During that hospitalization , he underwent bilateral ischial wound debridement with left ischial bone biopsy by general surgery. Cultures grew klebsiella pneumoniae, proteus mirabilis, enterococcus faecalis, enterococcus faecium, corynebacterium, bacteroids thetaiotaomicron. Surgical pathology was consistent with necrotic skin and soft tissue with acute inflammation and acute osteomyelitis. On 2/14/23 2:11 PM, V7 (Wound Clinic Registered Nurse/WCRN), I was the one that saw him today. (V28 Nurse Practitioner), assessed his wounds and he had signs of infection in his right hip wound along with a low blood pressure, elevated heart rate and fever, so she had him sent to the ER for possible sepsis. If the facility identified a foul smell with necrotic tissue yesterday during his wound vacuum dressing change, they should have contacted us prior to putting the wound vacuum back on because his symptoms indicated an infection. 2/14/23 at 2:24 PM, V3 (Assistant Director of Nursing/ADON), stated I changed the wound vacuum yesterday and noticed the wound had a foul smell with some necrotic tissue. When I changed it yesterday, I knew he had an appointment today, so I didn't contact the wound clinic or his physician because I knew he was going to the wound clinic today. Yes, the foul smell and necrotic tissue typically indicates an infection. If the resident is being followed by a wound clinic, we normally notify the clinic of any wound changes, but like I said, he was being seen the next day and that's why I didn't. I guess it was just poor communication of why I didn't notify anyone. On 02/15/23 at 9:17 AM V7 (WCRN) stated After our conversation yesterday, I spoke to (V28 NP) about (R7). She agreed that the facility should have called when they noticed the foul smell and necrotic tissue in his right hip wound. It indicates a possible infection and given his history of sepsis; we would have had him sent to the ER for evaluation instead of waiting the next day for his appointment. I looked at his medical record he's currently in the ICU for septic shock. He shouldn't have waited for his appointment here. He should have gotten immediate treatment when they identified the infection. R7's hospital medical record dated 2/14/23 documents R7 was admitted to the intensive care unit for septic shock and pressure injury of contiguous region involving right buttock and hip, stage IV. 30678 2. On 2/14/23 at 10:20 AM, R18 was lying in bed on her back and stated I have a sore near my tailbone that is very painful. They just gave me some medicine so hopefully will be better soon. 02/15/23 at 11:15 AM V3 (ADON/Wound Nurse) stated she is not aware of any pressure ulcers to R18's bottom and R18 is not on her list of wounds to assess weekly. On 2/15/22 at 11:22 AM, V24 (Certified Nursing Assistant/CNA) and V3 assisted R18 onto her left side, removed R18's incontinence brief and revealed an open area to R18's coccyx area that did not have any ointment or dressing over it. V3 stated the wound is an open stage II pressure ulcer and measures 1.0 cm (centimeters) by 0.2 cm with depth of 0.2 cm. V3 stated she was unaware of R18's pressure ulcer and the staff should have notified her at the time they found it. V3 stated she would call R18's doctor and get a treatment order. On 2/15/23 at 11:35 AM, V2 (Director of Nurses/DON) stated she spoke with the nurse who took care of R18 yesterday and said the nurse saw the area and notified hospice yesterday but forgot to chart it. On 2/15/23 at 12:02 PM V26 (Hospice Registered Nurse), stated she was at the facility on the morning of 2/14/23 and R18 had complained to her about her bottom being sore and when (V26) asked the nurse about it the nurse said it was only a small shearing area. V26 stated she asked the nurse specifically if the area was a pressure ulcer and the nurse said no. V26 stated no one called her about a pressure ulcer on R18's bottom. On 2/15/23 at 12:45 PM, V25 (Licensed Practical Nurse/LPN), stated she was the nurse for R18 on 2/14/23 and only saw a friction/shearing area to R18's sacrum that measured about 2 cm. V25 stated the area was only red at the time and was not open. V25 stated she did not call R18's family or R18's Physician and probably should have. V25 stated she thought V26 (Hospice RN) would notify the family. The Progress Note for R18, dated 2/14/23 at 1:00 pm, documents During cares patient observed to have skin shearing/red in color, area to coccyx. Area was not open. No drainage or warmth to area. Hospice nurse was at facility at the time, and it was reported. Hospice nurse stated we may use topical cream or zinc to area daily and prn until resolved. Zinc cream was applied to area at this time. The Physician Order Summary, dated 2/15/23, does not include any pressure ulcer treatment orders for R18.

Based on observation, interview, and record review the facility failed to keep dietary worker certifications up to date. This failure has the potential to affect all 104 residents who consume food in the facility except R74 and R99 who are NPO (Nothing by Mouth). Findings include: The Dietary Cook and Aide Job Descriptions, undated, documents a qualification of Must meet all local health regulations. On [DATE] at 12:30 PM, V11 (Cook) and V13 (Dietary Aide) were in the kitchen handling food and food items in preparation for the lunch meal. On [DATE] at 9:50 AM, V9 (Dietary Manager) stated that V9 has 15 staff members and that their certificates are either expired or not available for most all of the dietary staff. V9 stated V9 has been notifying Corporate for the need to get staff certified with food handler's certificates since Corporate would be the ones who would be paying for it. V9 stated that V9 has not gotten a response. At this time, V10's (Dietary Aide) Food Handler Certificate was posted on the outside of V9's office window. This certificate has an expiration date of [DATE]. V11's (Cook) Food Service Sanitation Manager Certification was posted on the outside of V9's office window. This Certificate has an expiration date of [DATE]. The local state agency website https://dph.illinois.gov/topics-services/food-safety/food-handler-training.html states, Food employee or food handler means an individual working with unpackaged food, food equipment or utensils, or food-contact surfaces and documents any food handler in Illinois is required to have food handler training. This same website states, Food Handler Training: Food Handler Training is still required for ALL paid employees who meets the definition of a food handler in both restaurants and non-restaurants within 30 days of hire, unless that food handler has a valid Certified Food Protection Manager (CFPM) certification. The ANSI (American National Standards Institute) food handler training certificates are good for three years and those taking other types of training that work in restaurants and other non-restaurant facilities, such as nursing homes, licensed day care homes and facilities, hospitals, schools and long-term care facilities, are good for three years. The facility's list of dietary personnel with hire dates provided by V9 (Dietary Manager) on [DATE] documents the following start dates for dietary personnel: V10 (Dietary Aide) [DATE]; V11 (Cook) [DATE]; V12 (Cook) [DATE]; V13 (Cook) [DATE]; V14 (Dietary Aide) [DATE]; V15 (Dietary Aide) [DATE]; V16 (Dietary Aide) [DATE]; V17 (Dietary Aide) [DATE]; V18 (Dietary Aide) [DATE]; V19 (Dietary Aide) [DATE]; V20 (Dietary Aide) [DATE]; V21 (Dietary Aide) [DATE]; V22 (Dietary Aide) [DATE]; and V23 (Dietary Aide) [DATE]. On [DATE] at 10:34 AM, V9 stated that V9 was not able to provide any current Food Handler Certificates for the above employees. V9 stated their employee files were checked and no record of the Food Handler Certificates being completed could be located in the facility. V9 stated, I am getting everyone signed up now. V9 verified that all dietary staff members should have current Food Handlers Certificates. The Resident Census and Condition of Residents signed and dated by V1 (Administrator) on [DATE] documents 104 residents currently reside in the facility.

Based on interview and record review the facility failed to refer one resident (R25) with a new diagnosis of a Serious Mental Illness to the state-designated authority for review of two residents reviewed for PASRR (Preadmission Screening and Resident Review) in the sample of 47. Findings include: Facility Policy/PASRR (Pre-Admission Screening/Resident Review) dated 6/14/22 documents: The purpose of PASRR is to ensure individuals who are being considered for placement in a Medicaid-certified Nursing Facility (NF), regardless of payor are appropriately institutionalized and are receiving the services/support needed for the NF setting: Evaluated for a serious mental illness (SMI), and/or an intellectual disability or related conditions. Level I - Regardless of payer an individual who applies to reside in a Medicaid-certified NF are required to have a pre-admission screening to determine whether a resident has SMI or ID and is appropriate for a NF setting. In-house residents who experience a change of status in their condition, will need a Level I Resident Review (RR) screen. OBRA (Omnibus Budget Reconciliation Act) Interagency Certification of Screening Results indicates R25 was screened (pre-admission) on 7/28/20. Current diagnosis list indicates R25 was diagnosed with Schizoaffective Disorder, Depressive Type on 1/10/23. On 2/15/22 at 3:45pm V5 (Social Service Director) stated a Level l determination was not done because the resident remained in the facility without a SMI (Serious Mental Illness) diagnosis, however due to the new Schizoaffective diagnosis, R25 should be re-screened. Progress Note dated 2/16/23 at 8:38am indicates Submitted PASRR for change Update.

Based on interview and record review, the facility failed to develop a plan of care for two residents (R30 and R49) of 47 residents reviewed for comprehensive care planning in the sample of 47. Findings include: The facility's Comprehensive Assessments and Care Plans, revised 4/5/21 documents: The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan - (C) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (D) Any updated information based on the details of the comprehensive care plan, as necessary. 1. The Medical Diagnoses listed for R30 include: Nontraumatic Intracerebral Hemorrhage in subcortical hemisphere, Malignant Neoplasm, Hemorrhage of anus and rectum, Diabetes type 2, Gastrointestinal Hemorrhage, and Vascular Dementia. The Physician Order Summary for R30, dated 2/17/23, documents Discharge of OT (occupational therapy) to patient going hospice on 1/11/23. This same Order Summary documents senile degeneration of the brain as the hospice diagnosis on 2/14/23. The current Care Plan for R30, as of 2/14/23, does not include a comprehensive care plan was developed for R30. On 2/17/23 at 8:24 am, V4 (Care Plan Coordinator/CPC) confirmed R30 is receiving hospice services. V4 stated R30 went back on Hospice on 1/16/23 and should be on his care plan. V4 stated someone resolved R30's hospice care plan on 2/3/23. V4 does not know why and shouldn't have been. 41869 2. R49's medical record documents an admitted [DATE]. R49's current care plan does not document a history of suicidal ideations. R49's POS (Physician Order Sheet) dated 1/13/23 documents Quetiapine Fumarate (Seroquel/Anti-Psychotic) 200 milligrams (mg) Tablet. give one tablet by mouth one time a day for na (Not Applicable) R49's medical record dated 1/20/23 documents Patient reports he takes Seroquel for suicidal ideations. Suicidal ideation, treatment resistant depression precipitated by chronic illness and paralysis from congenital spina bifida. Patient reports has a long history of suicidal ideation and was placed on medication by primary psychiatrist for persistent suicidal thoughts. Patient reports that he remains on antipsychotic medication for major depressive disorder recurrent, and patient declines to change medication prescribed by primary psychiatrist familiar with history of condition, and further believes that any change made in medication may precipitate the return of thoughts of suicide and being better off dead. Patient further reports that medication should not be changed by facility nurse practitioner as patient is short term resident there for skilled care. On 02/15/23 10:52 AM, V2, Director of Nursing verified there is no identified diagnosis for R49 taking Seroquel and stated I don't know why (R49) is taking it. Him and his parents told us the Seroquel was for sleep, but he takes it in the morning. He has Melatonin he takes at night for sleep. I sent an email to our behavioral health service to evaluate him for the Seroquel, but I never heard back of why he's taking it. Oh wait, there's a note in here from (V28, Psychiatric Nurse Practitioner) on 1/20/23 that he's taking Seroquel for a history suicidal ideations and severe depression. Ok, that's why he's taking it. On 02/15/23 12:10 PM V4 (CPC) verified R49's care plan does not include suicidal ideations and stated I was not aware that (R49) had a history of suicidal ideations. I was told he's taking Seroquel for sleep, not suicidal ideations. If I knew he had a history of Suicidal ideations, I would have definitely added it to the care plan, but no one told us. Yeah, I see it here in the psychiatric visit note on 1/20/23 indicating it. This is the first I'm hearing this. Had we known he had a history of suicidal ideations, myself and V5 (Social Services Director) would have talked to him and (V5) would have done an evaluation on him.

Based on observation, interview, and record review the facility failed to revise the dialysis care plan access site for one resident (R25) of three residents reviewed for dialysis in the sample of 47. Finding include: Facility Policy/Comprehensive Assessments and Care Plans dated/revised 4/5/21 documents: The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan- (C) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (D) Any updated information based on the details of the comprehensive care plan, as necessary. On 2/14/23 1:30pm R25 stated that her dialysis access is in her left upper chest. R25 stated that dialysis takes care of the dressing. Current Care Plan indicates staff are to monitor shunt for bruit and thrill. On 2/16/23 at 9am V2 (Director of Nurses) confirmed that R25 has a dialysis access port in her chest - not a shunt - and R25's care plan should have been updated.

Based on observation, interview and record review, the facility failed to ensure residents who required the assistance of staff for Activities of Daily Living/ADLs were provided ADL care to include the removal of unwanted facial hair and oral care for two of three residents (R18 and R74) reviewed for Activities of Daily Living in the sample of 47. Findings include: The facility's Standards and Guidelines: SG ADL Care and Assistance Policy, revised 3/27/21, states, Standard: It will be the standard of this facility to provide the resident with Activities of Daily Living (ADL) care and assistance while attempting to maintain the highest practicable level of function for the resident. Personal Hygiene: How a resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers). 2. Each ADL should be provided at the level of assistance that promotes the highest practicable level of function for the resident, while ensuring the needs and desired goals of the resident are met safely. 3. Staff should be mindful to provide ADL care with dignity, privacy and respect to the resident, unless otherwise indicated by the resident. 1. R74's Face sheet documents R74 admitted to the facility on [DATE] with diagnoses to include but not limited to: Cerebral Infarction; Flaccid Hemiplegia affecting left dominant side; Need for Assistance with Personal Care; Nontraumatic Intracerebral hemorrhage; Obesity; Lack of Coordination; Muscle Wasting and Atrophy; and Weakness. R74's current Order Summary Report documents that R74 is NPO (Nothing by Mouth) and receives enteral tube feedings. R74's current Care Plan documents R74 with following: requires assistance with ADLs stating that R74 is dependent on assistance with personal hygiene; has hemiparalysis on the left side of R74's body; and needs assistance to complete oral care tasks. This same Care Plan states, Assist with or provide mouth care as needed to ensure task completion. Review ADL Care Plan interventions for degree of assistance needed. R74's Minimum Data Set (MDS Assessment) dated 12/21/22, documents R74 with severe cognitive impairment and requires extensive assistance of one personal physical assist for personal hygiene. R74's MDS Assessments dated, 12/21/22, 12/29/22 and 2/7/23 documented R74 had no rejection of cares during the seven day look back period. As of 2/15/23, R74's Point of Care Response History for the task bathing/showers states the question, Was the resident's face shaved? For a look back period of 30 days, this question is only answered as yes on 1/19/23. On 02/14/23 at 10:50 AM, R74 was seen lying in bed in R74's room. R74 was alert and able to answer questions well. A large cluster of long, curly white and gray strands of hair, approximately one to one and a half inches long were noted to R74's chin and extended down onto her neck. R74's mouth was dry with a thick white cakey substance noted to the corners of R74's mouth. R74's lips were dry and chapped. A small dried bloody area was noted to the center of R74's bottom lip. At this time, R74 stated, I can't eat or drink, so my mouth gets dry. On 02/15/23 at 11:42 AM, R74 was seen lying in bed in R74's room. R74 was alert, answering questions well. R74 continued to have the large cluster of long, curly white and gray strands of hair, approximately one to one and a half inches long on R74's chin extending down onto her neck. R74's mouth remained dry with the thick white cakey substance on the corners of R74's mouth. R74's lips were dry and chapped. A small dried bloody area was noted to the center of R74's bottom lip. When asking R74 about R74's facial hair and mouth care, R74 stated, Nobody does anything with them (chin and neck hairs). I want them to. I used to tweeze them when I was at home. R74 stated, My lips are dry. I wish I had (lip balm). They just put me in this room and forget about me, that's how I feel. On 02/15/23 at 11:51 AM, V2 (Director of Nursing) entered R74's room. At this time, V2 verified that R74 has long chin and neck hairs that should be removed and R74's mouth was dry with buildup. V2 attempted to locate supplies in R74's room to perform oral care and moisten R74's mouth. No supplies were able to be located in R74's room. V2 stated that R74 requires assistance for ADLs and V2 would notify staff to assist R74. V2 stated that residents should be shaved on their shower days and as needed. 30678 2. The Medical Diagnoses form includes the following diagnoses for R18: Fracture of fifth Lumbar Vertebra, Stage 4 Chronic Kidney Disease, Tubulo-Interstitial Nephritis, Muscle wasting and Atrophy, and Malignant Neoplasm of Head, Face and Neck. The Admission MDS (Minimum Data Set) for R18, dated 1/8/23, documents R18 is cognitively intact with no behaviors. This MDS documents R18 requires extensive assist of one staff for personal hygiene. The current Care Plan for R18, documents focus area that R18 has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) ADL needs and participation vary with intervention as Resident currently requires assistance with ADL's. The Care Plan lists focus area that R18 has potential fluid imbalance r/t Heat exposure and poor intake with goal of adequate fluid volume balance AEB (as evidenced by) good skin turgor, pink and moist mucous membranes, and sufficient fluid intake. Interventions include offering fluids, activities, and monitoring fluid consumption and report abnormalities. This same Care Plan documents focus area that R18 has potential for an actual oral health concerns. Has functional limitations and needs assistance to complete oral care tasks. Interventions include: assist with, or provide mouth care as needed to ensure task completion. On 2/14/23 at 10:20 AM, R18 was lying in bed with malnourished appearance and oral cavity was coated with dry thick white substance with same substance dried and caked to her teeth. R18's lips were dry with white substance dried to lips and corners of her mouth. During this time R18 was having difficulty moving lips and tongue due to dryness. R18 stated the staff have helped here a couple of times with cleaning her mouth since she came to the facility. At this time there was a full glass of water noted on bed side table out of resident reach. On 2/15/23 at 11:22 AM, R18 was lying in bed with same dry oral cavity appearance, thick white substance covering teeth, lips, and corners of mouth. R18 stated her mouth is dry a lot of the time and she needs help when drinking and can't reach her water. During this same time there was a bed side table with a full glass of water out of resident reach. On 2/15/23 at 11:22 AM, V24 (Certified Nurse Assistant) confirmed R18 was in need of oral care.

Based on observation, interview, and record review the facility failed to ensure indwelling urinary catheters were not placed on the floor to prevent contamination for two (R18 and R30) of six residents reviewed for indwelling catheter care in the sample of 47. Findings include: The facility Indwelling Catheters policy and procedure, Revised 3/27/21, documents 10. Staff should ensure proper placement of the catheter tubing as to ensure that it is not kinked, pulling excessively and allows for gravity drainage. The facility Prevention of Catheter Associated Urinary Tract Infections policy and procedure, Revised 11/5/22, documents 9. Keep the collection bag below the level of the bladder. Do not rest the bag on the floor. 1. The Physician Order Summary, dated 2/15/23, documents a physician order on 1/3/23 as insert/maintain indwelling catheter 16FR (French type and size of catheter) Neuromuscular dysfunction. On 2/15/23 at 11:22 AM, R18 was lying in bed with her indwelling urinary catheter bag resting on the floor in a large pool of urine. On 2/15/23 at 11:25 AM V24 (Certified Nursing Assistant/CNA) confirmed R18's indwelling urinary catheter bag was resting on the floor in a pool of urine and stated she is unsure what happened or why there is urine on the floor. V24 CNA stated no catheter bag or tubing should be on the floor. 2. The Physician Order Summary report for R30, dated 2/17/23, documents a physician order for 1/12/23 to Insert/maintain indwelling catheter (16 French) - obstructive uropathy. On 2/14/23 at 10:12 AM R30 was lying in bed with an indwelling urinary catheter in place with the catheter tubing coiled up and resting on the floor. R30 stated he can't pee as the reason for having the catheter.

Based on observation, interview and record review, the facility failed to obtain a physician order for care of a resident's Gastrostomy site and failed to provide care to a resident's Gastrostomy site for one of one resident (R74) reviewed for tube feedings in the sample of 47. Findings include: The facility's Standard and Guidelines: SG Enteral Tube Feeding Policy, revised 3/27/21, states, 13. Provide cleaning and dressing changes as ordered to enteral tube feeding sites. R74's Face sheet documents R74 admitted to the facility on [DATE] with diagnoses to include but not limited to: Cerebral Infarction; Gastrostomy Status, Flaccid Hemiplegia affecting left dominant side; Need for Assistance with Personal Care; Nontraumatic Intracerebral hemorrhage; Feeding Difficulties; and Weakness. R74's current Care Plan documents R74 requires a tube feeding due to a stroke. This same Care Plan documents an intervention to provide skin care to R74's feeding tube insertion site daily and as needed. R74's After Visit Summary Report, dated 2/10/23, documents R74 was hospitalized from 2/7/23 to 2/10/23 for PEG (Percutaneous Endoscopic Gastrostomy) Tube Malfunction. This same report documents care of the feeding tube includes keeping the skin around the tube clean and dry. On 02/14/23 at 11:30 AM, V8 (Licensed Practical Nurse) entered R74's room to administer pain medication via R74's Gastrostomy Tube/G-Tube. R74's feeding tube was noted to have a large amount of gauze with a transparent adhesive dressing bunched up and tangled around R74's G-tube. The edges of the transparent adhesive dressing were rolled up and not secured to R74's skin. V8 struggled manipulating the gauze to administer R74's medication. V8 stated, This needs cut off. At this time, V8 stated it was possible this gauze was R74's original dressing after returning to the facility from the hospital that had fallen off. V8 lifted R74's gown up to expose R74's G-tube insertion site. R74's G-tube insertion site was noted with a large amount of brown-crusty build-up directly around R74's insertion site and on R74's surrounding skin area, measuring approximately one inch in diameter. On 2/14/23 at 11:35 AM, V8 stated that V8 had not performed G-Tube site care for R74 since R74 returned from the hospital on 2/10/23. V8 stated, I haven't had any orders for the (G-Tube site) care to be completed on my shift. V8 stated that V8 has taken care of R74 previously since R74's return from the hospital on 2/10/23 and V8 did not complete G-Tube care on those shifts either. V8 stated that before R74 left the facility (on 2/7/23), V8 recalls R74 having a previous order for G-Tube site care. V8 verified that R74's G-tube site and surrounding skin needed to be cleansed. On 2/14/23 at 11:40 AM, V2 (Director of Nursing) verified that R74's G-Tube site care should have been added as a physician order once R74 returned back to the facility after having R74's tube replaced, and it wasn't. V2 stated that there is an order set for feeding tubes that gets initiated and a specific order for site care is not part of that set. V2 stated the insertion site care has to be added separately. V2 stated, I am going to talk to Corporate about getting that added. As of 2/14/23 at 12:00 PM, R74's medical record did not contain a current order for G-Tube site care and did not contain any documentation that G-Tube site care had been completed since R74's return from the hospital on 2/10/23.

Based on record review and interview, the facility failed to provide an adequate number of staff assistance during cares to prevent a resident from falling out of bed for one of three residents (R1) reviewed for falls in the sample of 31. Findings include: The facility's Fall policy, dated 3/27/21, documents, It will be the standard of this facility to complete an initial assessment, on-going monitoring/evaluation of resident condition and subsequent intervention development in an attempt to prevent falls and injuries related to falls. R1's Admission Height & Weight, dated 8/19/22, documents that R1 was admitted to the facility on [DATE] weighing 295 lbs (pounds). R1's Care plan, dated 6/29/22, documents, R1 has an ADL (Activities of Daily Living) self-care performance deficit related to ADL needs and participation vary. Interventions: Bed mobility extensive, Transfer extensive two staff members. The care plan also documents that R1 has the following diagnoses: Chronic pain syndrome, [CONDITION(S)], Idiopathic progressive [CONDITION(S)], Lumbar region radiculopathy, [CONDITION(S)], and Cerebral Infarction. R1's Fall care plan, dated 6/29/22, documents, R1 is at risk for falls related to experiences weakness. The care plan also documents the following intervention: Anticipate and meet resident's needs. R1's Physical Therapy Plan of Care, dated 6/29/22, documents, Reason for referral: Medically complex. R1 presents to therapy with multiple conditions, including progressive idiopathic [CONDITION(S)], lumbar radiculopathy. R1 has shown a significant decline in bed mobility and transfers over the past three months, and gait over the past year due to medically complex conditions resulting from multiple medical co-morbidities resulting in weakness, chronic pain, and reduced sensation bilateral lower extremities impacting balance. The plan of care also documents, Functional Deficits: Mobility roll left and right: Current level dependent helper does all of the effort. R1 does none of the effort to complete the activity. The assistance of two or more helpers is required for R1 to complete the activity. Short term goals: Current level of Function: R1 is able to roll from side to side requiring dependent (100% assist). Goal: R1 will safely roll from side to side increasing to maximum assistance (76-99% assist with two people). R1's MDS (Minimum Data Set), dated 7/1/22, documents that R1 required two persons extensive assistance for bed mobility and personal hygiene. R1's Fall report, dated 7/2/22 at 9:15 a.m., documents, (V4 CNA-Certified Nursing Assistant) was giving cares to R1 and R1 rolled out of bed. Bed was raised up. R1 landed face down. 911 called for R1 to go to hospital to be evaluated due to being on blood thinners. R1's Emergency Department Physician notes, dated 7/2/22, documents, R1 presents with fall, shoulder pain. Onset: 7/2/22. Today had a fall when he was rolled in bed at the facility. Landed on right side. Primary complaint is right shoulder. Pain scale 5/10. On 8/18/22 at 1:50 p.m., V4 (CNA) stated, (R1) is a large man. I've provided cares to him previously by myself without any problems. He was holding himself over and I don't know if his hand slipped or what, but he rolled out of the bed. On 8/18/22 at 2:55 p.m., V22 (Director of Rehab) stated, The admitting nurse will get the transfer status from whoever is discharging the resident. Then, when we evaluate him if that needs changed, we will let the staff know of our findings. (R1's) Physical Therapy evaluation showed that he required maximum assist of two person assist. His goal was to discharge with two-person assist just not completely dependent. When he was discharged , he still required a two person assist. I'm looking at all of his therapy notes and at no point do I see that his bed mobility status ever changed to one person assist. On 8/19/22 at 2:50 p.m., V5 (R1's Power of Attorney) stated, My dad (R1) has no control of his upper and lower body. He is like a large three-month-old baby. There is no way that only one staff member could take care of him in the bed. He was too large and couldn't do anything to help. When we returned to the facility that afternoon the staff were very apologetic and told us there never should have only been one person providing cares to him while he was in bed. He always required two-assist.

Based on observation, interview, and record review, the facility failed to ensure residents were served palatable meals. This failure has the potential to affect all 97 residents in the facility. Findings include: The facility's Diet Meets Needs of Each Resident policy, dated 2/19/21, documents, The purpose of the food and nutrition services department is to provide high quality, nutritious, palatable, and attractive meals in a safe, sanitary manner. Guidelines: To provide food and drink that is nutritious, palatable, attractive, and at a safe and appetizing temperature to meet individual needs. The facility's Resident Council Meeting Minutes, dated 7/28/21, document, New Business: FNS (Food and Nutrition Services): Temperature of foods. The facility Concern form, dated 7/28/21, documents, Concern: Temperature of food. Investigation results: Some food is cold when residents get it. Action taken: Make sure all food is covered and sent down halls as soon as it is plated. The facility's Resident Council Meeting Minutes, dated 10/29/21, document, New Business: FNS: Temperature of food. The facility's Resident Council Meeting Minutes, dated 11/18/21, document, Old Business: FNS: Temperature of foods. New Business: FNS: Temperature of food. The facility Concern form, dated 11/18/21, documents, Concern: Meals at a hotter temperature. Investigation results: Food was cold by the time the residents received meals. Action taken: Make sure doors to carts are closed, all plates have covers. The facility's Resident Council Meeting Minutes, dated 12/23/21, document, New Business: FNS: Temperature on the food. The facility Concern form, dated 12/23/21, documents, Concern: Temperatures on the food not hot enough. On 03/28/22 at 11:40 AM, R69 stated, Food is cold and it sits in the hall before we can get it delivered. On 3/28/22 at 12:00 PM and on 3/29/22 at 12:00 PM a meal cart was on the AAA Hall with the door open. The staff were taking meal trays off the cart and taking the trays into resident rooms one by one. During this time, the meal cart was left open. On 3/28/22 at 12:05 PM, R100 stated, The food is cold. I always eat in my room, so I just deal with it because I don't want to go out there to eat. On 3/28/22 at 12:44 PM R29 stated, The food is always cold. They even have the new black things (meal carts), but the food comes cold. On 3/29/22 at 8:54 AM, R29 stated, My breakfast is not hot this morning. It is warm but not hot like it should be. On 03/29/22 at 09:29 AM, R27 stated, The food is so awful. I don't even want to talk about it because it's so bad. On 3/29/22 at 11:56 AM, R8 stated, My biggest thing is the food is not hot when it gets to me. On 03/29/22 at 12:35 PM, R79's lunch plate was sitting on R79's bedside table with chicken pot pie and asparagus. The plate appeared to have only one bite taken out of the chicken pot pie. When R79 was asked how the food was, R79 pointed to the plate and stated, That should tell you something I didn't eat any of it. It does not taste good. On 03/29/22 at 12:36 PM, R252 was sitting upright in R252's bed. R252 was served a room tray of asparagus and a potato chicken carrot mixture. R252 stated it was chicken pot pie. R252 took a bite of the pie and stuck out R252's tongue stating it was not good it tasted funny, and the asparagus was hard not cooked all the way. On 03/29/22 at 12:40 PM, R27 was served a room tray of chicken pot pie, asparagus, and cherry pie. R27 took a few bites from her chicken pot pie, and stated, This isn't good. On 03/30/22 at 12:30 PM, V4 (Dietary Manager) delivered a test meal tray containing pot roast with gravy, mashed potatoes with gravy, mixed vegetables, wheat roll, and blueberry cheesecake. Meat, potatoes, and vegetables were lukewarm to the touch. Pot roast temperature was 120 degrees F (Fahrenheit), mashed potatoes 130 degrees F, and the vegetables were 110 degrees F. The pot roast was bland to the taste. On 03/30/22 at 02:21 PM, V4 stated, When a resident receives their plate of food the temperatures should be no less than 135 degrees F. Below 135 degrees F is in the danger zone. When the CNAs (Certified Nursing Assistants) deliver the meals from the meal cart, the covers should remain on the plate until it reaches the resident. When staff remove a tray from the meal cart, the doors should be immediately closed to keep the heat in. I have only been here two months, and I wasn't aware of the residents complaining of cold food. The facility's CMS (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents Form 672, dated 3/28/22 and signed by V11 (Licensed Practical Nurse), documents that 97 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to follow the menu for residents receiving a pureed texture diet. This had the potential to affect seven residents (R2, R12, R33, R56, R61, R73, R97) who receive a Physician ordered pureed texture diet. Findings include: The facility Concerns form, dated 7/28/21, documents, Concern: Menu isn't matching what they are receiving. Investigation results: When stuff (food) is subbed on menu or doesn't come on truck (delivery), residents don't know. The facility's Week at a Glance-Master Menu, dated 3/28/22, documents that the pureed texture menu for 3/28/22 is pureed meatballs, 3/8 cup of pureed buttered noodles, 1/4 cup pureed green peas, pureed dinner roll, and pureed cookie blondies. On 03/28/22 at 12:01 PM, the facility's steam table contained serving pans of meatballs, buttered noodles, peas, gravy, pureed meatballs, pureed peas, mechanical soft meatballs, and mashed potatoes. On 03/28/22 at 12:22 PM, V4 (Dietary Manager) was preparing R33's meal plate for lunch. V4 placed pureed meatballs mashed potatoes and gravy, pureed peas, and pureed cake on R33's plate. R33's meal card that was on R33's tray documents that for R33's lunch meal, R33 is to receive pureed meatballs, pureed butter noodles, pureed peas, and pureed bread. On 03/28/22 at 12:30 PM, V6 (Cook) stated, I made the pureed food. I didn't make pureed butter noodles. I made mashed potatoes instead. If there are noodles on the menu, we always make mashed potatoes and not the noodles. On 03/28/22 at 12:32 PM, V4 stated, We don't make the noodles if they are on the menu. The only time I'd say we make the noodles is if they are having macaroni and cheese. The facility's Diet Type Report, dated 3/30/22, documents that 7 residents (R2, R12, R33, R56, R61, R73, R97) receive a Physician ordered pureed texture diet.

Based on observation, interview and record review the facility failed to implement fall prevention interventions for one resident (R1) of three residents reviewed for falls. This failure resulted in R1 sustaining a ground level fall resulting in a [CONDITION(S)] injury that required local emergency room Care and sutures. Findings include: Facility Fall Prevention policy, revised 3/27/21, documents: It will be the standard of this facility to complete an initial assessment, on-going monitoring/evaluation of resident condition and subsequent intervention development in an attempt to prevent falls and injuries related to falls; The staff will discuss the resident's risk factors for falling and obtain orders from the Physician for appropriate fall preventative devices as needed; After a fall, the interdisciplinary team (IDT) should review the circumstances surrounding the fall and develop an appropriate intervention and plan of care; And if the cause of the fall is unclear, the IDT will attempt to establish reasonable interventions related to the current condition of the resident to attempt to prevent recurrence. The Facility's Initial Federal Report, dated 7/7/21, documents that on 7/1/21, (no time documented), R1 was observed laying on the floor in a prone (on stomach) position. Upon assessment, bleeding was noted to the right eyebrow as well as a hematoma above right eye. This Report does not document non-skid socks on R1. R1 was sent to the local Emergency Department for evaluation and treatment. R1 was found to have a two centimeter/cm laceration about right eye that required four sutures. R1's Hospital Record, dated 7/1/21, documents that R1 presented to the Emergency Department with a fall. A Computed Tomography/CT of the Facial Bone, Maxillofacial Forehead, Orbit/Periorbital area and Cervical Spine was completed. Findings included swelling, contusion and laceration to the right eye and right side of the forehead, requiring four sutures. On 7/11/21, at 9:05 am, R1 was lying in bed on R1's back with R1's eyes closed. R1's right forehead and cheekbone were yellow/brown in color and four sutures above R1's right eyebrow were noted. R1's Nursing Note, dated 6/29/21, at 10:19 pm, documents that R1 had a fall at 9:40 pm. This Notes states, (R1) was found sitting on the side of (R1's) bed. (R1) had no apparent injuries at this time. (R1) is alert and confused within (R1's) normal with drowsiness that is not a new change. (R1's) Power of Attorney (POA) and Hospice (Local Hospice Agency) on call Nurse aware. Hospice contacted about low bed with floor mats. R1's Nursing Note, dated 6/29/21, at 10:35 pm, documents, Neuro (Neurological) checks in place. Hospice stated they would order floor mats. R1's Nursing Note, dated 6/29/21, at 11:39 pm, documents, Non-skid socks were put into place at time of fall. R1's Nursing Note, dated 6/30/21, at 6:29 am, documents, (R1) up all night with staff at nurses station, would not stay in bed, offered food and beverage, no behaviors, no ideations of self-harm voiced, (R1) now in bed sleeping will continue to monitor. R1's Nursing Note, dated 7/1/21, at 5:02 am, documents that R1 was noted face down on floor next to R1's bed at 3:25 am. The Nursing Note does not document that R1 had on non-skid socks or that a low bed or fall mats were in place. R1 was noted to have a laceration and hematoma above the right eyebrow with moderate bleeding from the laceration. R1 was sent to the local Emergency Department for sutures of the laceration. R1's Nursing Note, dated 7/1/21 at 11:37 am, documents that R1 has a Laceration above the right eye with sutures and bruising that is purple with a hematoma. R1's current Care Plan, dated 6/29/21, documents 6/29/21 Fall Interventions of Non-Skid Socks on 6/29/21, ordered Low Bed/Platform Bed on 6/30/21, delivered 7/1/21, and Dycem (non-skid adhesive) under floor mat on 7/1/21. R1's Minimum Data Set/MDS Assessment, dated 6/26/21, documents that R1 requires limited assistance with one-person physical assist for walking and toilet use. The MDS Assessment also documents that R1 requires extensive assistance for bed mobility and transfers. On 7/12/21, at 10:28 am, V3 (Registered Nurse/RN) stated, On 7/1/21, I was the nurse on duty when (R1) fell . It appeared that R1 was attempting to get out of bed. (R1) was lying face down on the floor and had blood and a laceration to his right forehead. I notified his Physician, Hospice and our Director of Nursing, and I sent him to the Emergency Department. (R1) did not have any socks on at the time of the fall (R1's) low bed and floor mats still had not been delivered yet from Hospice, and they were requested as intervention from the 6/29/21 fall. Our facility did not have a low bed or any fall mats available in house for (R1) because they were all being used. On 7/12/21, at 11:17 am, V4 (Hospice Registered Nurse) stated, We were notified on 6/29/21, at 10:24 pm, of (R1's) 6/29/21 fall and the facility requested that we order fall mats. According to our dispatch records, the fall mats' order was acknowledged and completed on 6/30/21 at 9:58 am. According to our Durable Medical Equipment/DME Supplier, it appears that the fall mats were delivered on 6/29/21, at 12:15 pm. We have no record from the facility requesting a low bed for (R1) and we never ordered a low bed at that time. On 7/11/21, at 4:38 pm, V2 (Director of Nursing/DON) stated, (R1) admitted with us on 6/2/21 and received therapy. Therapy ended on 6/11/21 and (R1) was put on Hospice. Then (R1) had the first fall out of bed on 6/29/21, at 10:04 pm, and our interventions were that we requested Hospice to order a low bed and fall mats and put non-skid socks on as an immediate intervention. Then, two days later, on 7/1/21 at 3:25 am, (R1) fell out of bed again and was sent to the hospital for a laceration above the right eye and required four sutures. (R1) was attempting to get out of bed on both falls. We did not get the low bed and floor mats in until after (R1's) second fall on 7/1/21, two days after we requested them for (R1's) first fall on 6/29/21. We did not have low beds or floor mats in the building, they were all being used by other residents. It usually does not take Hospice this long to get equipment in. The only intervention that was implemented on 6/29/21 was non-skid socks, while we were waiting for the equipment to come in. On 7/12/21, at 2:13 pm, V1 (Administrator/ADM) stated, Per a discussion with (V3), (V3) did have a recollection that (R1) did not have non-skid socks on and thought they were in (R1's) bed.

Based on observation, interview and record review the facility failed to construct a secure barrier between the COVID-19 positive unit and the non-COVID-19 unit, cohort quarantined residents, provide dedicated staff for the COVID-19 positive unit, follow transmission based precautions, provide an anteroom for donning and doffing of personal protective equipment (PPE) for the COVID-19 positive unit and failed to ensure non-quarantined residents, staff and vendors wore required PPE while in the facility during a COVID-19 outbreak. These failures resulted in the spread of COVID-19 among residents and staff and have the potential to affect all 102 residents residing within the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 5/18/21, the facility remains out of compliance at Severity Level 2. The facility is continuing to carry out walking round to monitor the anteroom for donning and doffing of PPE prior to entering the COVID-19 unit. The facility is also continuing to monitor and ensure the secured barrier is in place between the COVID-19 unit and non COVID-19 unit. The facility is also conducting walking rounds to ensure that all staff, vendors, residents and visitors are maintaining the appropriate PPE and that quarantined residents are not sharing rooms with non- quarantined residents. Findings Include: The current corporate Infection Control training for facility employees documents, Staff members required to wear a mask during their shift will be issued a mask that will be used until it becomes moist or otherwise degraded. The mask will be worn at all times, while in the facility, even when you are in an area by yourself such as an office. N95 and face shield/goggles to be worn at all times in the facility. PPE to be worn in isolation rooms. All residents out of room must have face mask on unless diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Facility Transmission Based Precautions policy revised 3/27/21 documents, A single resident room is preferred for residents who require droplet precautions. When a single-resident room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other resident placement options (e.g. cohort, keeping resident wit an existing roommate). The Facility COVID-19 Performance Improvement Plan/To House COVID Positive Residents dated 5/6/21 documents the following: - Barrier is to be closed at all times and free from penetration. - Consistent assignment to be carried out - Implement enhanced droplet/contact precautions. Wear gloves, gowns, goggles/face shields and masks (N95) covered with surgical mask, upon entering COVID-19 unit. - Keep resident room doors closed - if safe for resident. Facility will increase frequent monitoring of residents related to decreased visibility with doors closed. Education with staff regarding additional focus on resident safety and frequent observations. - Add signage on Unit Doors stating, Decreased Traffic on Hall If assignment limited to one unit. The Facility COVID-19 Performance Improvement Plan/To House COVID Positive Residents dated 5/6/21 documents the following: Compassionate visitors, vendors and practitioners are to wear N95, eye protection (and gown in an abundance of caution,). The Facility Policy/COVID-19 Exposure Control Plan/Outbreak Management revised 12/21/20 documents the following: Post signage at visitor/vendor entrances to notify staff if COVID-19 signs or symptoms are present. 1) On 5/11/21 at 12:50pm and 5/12/21 at 10:00am, during a tour of CCC hall, there was a plastic partitioned curtain at the far end of the unit. The plastic curtain had a zippered area in the center that was unzipped from floor to ceiling. One side of the curtain did not reach from floor to ceiling leaving an open area of approximately six inches across the entire bottom length of the curtain. No signage was present to designate the area as COVID-19 positive. There was also no signage to designate appropriate precautions to take when entering the COVID Unit. On 5/11/21 at 3:40pm, a tour of the COVID-19 unit at the end of CCC hall found the plastic partition still unzipped and unsecured at the floor. At that time V16, CNA (Certified Nurse Assistant) stated that staff were to don the required PPE after going through the plastic partition into the COVID positive unit. On the other side of the partition (within the COVID-19 unit), barrels containing clean linen gowns and other PPE were on one side of the hall. Directly across from the clean PPE were barrels identified as dirty - one barrel for soiled disposable items and one barrel for soiled linen gowns. To access the necessary clean PPE required walking past an open door identified as COVID positive resident/room. At that time, five residents were identified as being COVID-19 positive residing in three rooms on the unit. All of the resident room doors were open. On 5/11/21 at 3:55pm V16, CNA stated that there are no staff that stay in the COVID unit. V16 stated that the CNA and the nurse that are signed to the CCC hall have to take care of the residents inside and outside of the COVID unit. V16 stated that the facility does not use Agency staff. On 5/13/21 at 10:00am, the COVID unit zippered curtain remained unzipped and open between curtain and floor. All doors to COVID positive resident rooms were open during this time. On 5/13/21 at 12:20pm V2, DON (Director of Nursing) stated that the zipper on the partition to the COVID unit is broken. V2 also stated, (I am) Not sure for how long (the zipper had been broken). 2) On 5/14/21 at 1:10pm V20, Food Vendor Driver, was observed transporting boxes of food into the kitchen through the side entrance of the facility. V20 was not wearing any type of face mask or PPE to transport the boxes into the store room at the far end of the kitchen. There was no signage found outside of the entrance into the kitchen to notify vendors of COVID -19 Positive residents in the building or to instruct vendors on donning PPE prior to entrance into the facility. At that time, V20 was asked about wearing a mask into the facility. V20 stated that he has has been told by V6, CDM (Certified Dietary Manager) that he needs to wear a mask when entering the building, however he was preoccupied with talking on the phone (via an earpiece). On 5/14/21 at 1:30pm V6, CDM stated that there are only two delivery drivers and they have both been told to wear a mask into the kitchen. V6 acknowledged that there are no signs outside the entrance to the kitchen informing vendors of COVID status or necessary PPE. V6 stated, There should be signs posted. 3) On 5/12/12 at 12:00pm V9, LPN (Licensed Practical Nurse) stated that R50 is on quarantine because he received his 2nd COVID vaccine yesterday and needs to be quarantined for 14 more days. V9 stated that R83 (R50's roommate) is not in quarantine. At this time, R50 and R83's door had signs indicating Droplet precautions. R83 was observed roaming throughout the facility, often times not wearing a face mask/covering during frequent observations between 5/11/21 and 5/14/21. 4) R32's Physician orders, dated 5/5/21, documents Droplet Precautions - Presumptive for possible exposure every shift for 14 Days until 5/19/2021. On 5/11/21 at 2:30pm, V10 CNA, was observed passing ice water to residents on the DDD hallway. While R32 was in his room in bed, V10 went into R32's room only wearing an N95 mask and goggles. Outside of R32's room, there was a three drawer cart full of PPE and R32 had a sign on his door documenting, Special droplet/contact precautions in addition to standard precautions everyone must clean hands when entering and leaving room, wear face mask, wear eye protection (face shield or goggles) and gown and glove at the door. At that same time, V10 stated I do not know what (R32) is on isolation for and I was told not to wear PPE in an isolation room unless I come into contact with the resident. I am working with all the residents on this hall. On 5/11/21 at 3:10 PM, V2 Director of Nursing (DON) verified the facility was currently in an outbreak status for COVID-19, and staff should be wearing the appropriate PPE as documented by the signs on the doors. V2 also verified that the staff should be wearing PPE any time they go into an isolation room for any reason. 5) On 5/11/21 at 12:40 PM, V3, Infection Preventionist (IP) stated, All the residents that are on droplet isolation are quarantined to their room and not allowed out because they refused the vaccine. Because of the COVID-19 outbreak in the facility, the isolation of unvaccinated residents is for their protection. The vaccinated residents are not on isolation precautions and are allowed out of their room and throughout the facility. On 5/12/21 at 11:43 AM, R1 was sitting in dayroom watching television with no mask on. Facility staff were walking by R1 and did not remind R1 to put on a mask or face covering. On 5/12/21 at 12:00 PM, V3, IP, stated, All residents in the facility have been exposed to COVID-19 equally. That's why we quarantined the unvaccinated and allowed the vaccinated access to the facility. V2, DON, and V3, IP, stated the lock down procedures of the facility and the isolation of unvaccinated residents while at the same time allowing the vaccinated residents access to the facility was a direction given to them by the local health department. On 5/12/21 at 1:05 PM, V4, Local Health Department Nurse, stated, I've been in constant contact with (V2, DON and V3, IP) since the outbreak. We're not allowed to give directives, we're only allowed to help them with the resources and information put out by the CDC (Center for Disease Control) and CMS (Center for Medicare/Medicaid Services). The only thing we specifically discussed was the guidance given out in regards to communal activities because they were asking about Bingo. I never recommended the isolation of unvaccinated resident while at the same time allowing vaccinated residents to roam free in the facility. That's not allowed under the new guidance. On 5/12/21 at 2:03 PM, R83 was sitting in the front lobby with no mask covering R83's face. Facility staff were walking by R83 and not reminding resident to put on a mask or face covering. On 5/12/21, 5/13/21, 5/14/21, and 5/18/21, R1, R43, R80 and R83 were moving throughout the facility with no mask covering their face. Facility staff members passed by R1, R43, R80 and R83 and did not remind the residents to put on masks. On 5/13/21 at 3:00 PM, V3, IP, stated (R83) and (R50) share a room together, but since (R83) is vaccinated he's not in isolation. (R50) is in isolation because he's not vaccinated. (R83) is allowed to come and go and (R50) is quarantined to his room. V3, IP, verified that R14, R23, R27, R29, R36, R40, R50, R56, R71, R72, R73, R94 and R105 are all quarantined with droplet isolation precautions due to COVID-19 exposure, but their roommates are not on transmission based precautions and are free to come and go from the room and access the common areas of the facility. 6) On 5/14/21 at 11:50 AM, V25, Environmental Services, exited the environmental services office with no face mask or eye protection on and walked down the hall, that's next to the CCC and DDD unit nurses station, to the men's restroom, stopped, turned around and walked back down the hall to the environmental service office. V25 verified that V25 did not have a mask on and stated, I left my mask and eye protection in the office because I was just going to the bathroom. On 5/14/21 at 11:56 am, V1, administrator, stated, All employees are to wear face mask and eye protection at all times in the facility. 7) On 5/11/21 between 10:00 am and 3:00 PM, R89, R47, R75, R100 and R81 were residing in the CCC hall COVID-19 positive unit. During these times, there was not a dedicated Nurse or Certified Nursing Assistant/CNA working on that unit. On 5/11/21 at 12:15 PM, V22 CNA, entered the COVID unit. On 5/11/21 at 12:20 PM V22 CNA exited the COVID unit and walked up to the electronic charting system on the wall of the 300 hall. On 5/11/21 at 12:22 PM, V22 CNA stated, I am responsible for the residents on the COVID unit and also work the 300 hall in between. If one of the residents in the COVID unit puts on their call light, then I go in and answer it and come back out to help on CCC hall. There is no one person scheduled to stay on the COVID unit. On 5/11/21 at 12:50 PM, V11 RN (Registered Nurse) stated she is the only nurse scheduled for the CCC hall and COVID-19 unit. On 5/11/21 at 2:30 PM, during change of shift, V11 RN was giving report to V18 LPN (Licensed Practical Nurse) to take over as the CCC hall Nurse. 8) On 5/12/21 between 9:30 AM and 3:00 PM, R89, R47, R75, R100, and R81 were residing in the 300 hall COVID-19 positive unit and there was not a dedicated Nurse or CNA on the CCC hall COVID-19 positive unit. V11 RN was the CCC hall and COVID-19 unit Nurse for day shift and V12 RN was the second shift Nurse. On 5/12/21 at 12:00 PM, V24 CNA entered the COVID-19 unit and exited the unit into the CCC hall at 12:04 PM and began answering call lights on the non- COVID-19 CCC hall. On 5/12/21 between 11:00 AM and 12:00 PM, V11 RN entered the COVID-19 unit with medications and then exited the unit into the non- COVID-19 CCC hall. On 5/12/21 at 1:00 PM, V11 RN stated she is the nurse working the CCC hall. V11 stated she cares for all the residents on the CCC hall, including the residents on the COVID unit because they don't have enough nurses to put one nurse on the COVID unit. The Facility's CMS (Center for Medicare and Medicaid Services) Resident Census and Conditions of Residents form- 672, dated 5/12/21 signed by V1, Administrator, documents that 102 residents reside in the facility. The Immediate Jeopardy was identified on 5/11/21. The Immediate Jeopardy began on 5/5/21 when the facility failed to construct a secure barrier between the COVID-19 positive unit and the non-COVID-19 unit, cohort quarantined residents, provide dedicated staff for the COVID-19 positive unit, failed to follow transmission based precautions, provide an anteroom for donning and doffing of personal protective equipment for the COVID-19 positive unit and failed to ensure non-quarantined residents, staff and vendors wore required PPE while in the facility during a COVID-19 outbreak. V1, Administrator was notified of the Immediate Jeopardy on 5/18/21 at 10:33 AM. The surveyor confirmed through interview, observation and record review, that the facility took the following actions to remove the Immediate Jeopardy: 1. On 5/13/21, V7, Maintenance Director, retrieved and installed a new barrier to ensure no penetration between the COVID-19 positive unit and the COVID negative unit. 2. On 5/13/21, V2, Director of Nursing (DON), reviewed schedules to ensure dedicated staff for the COVID-19 positive unit. 3. On 5/18/21, V7, Maintenance Director, created an anteroom to provide an area to don and doff PPE for the COVID-19 positive unit. 4. On 5/18/21 V2, DON and V3, IP, ensured quarantined residents were not sharing a droplet isolation room with non-quarantined resident. 5. On 5/18/21, V1, Administrator, V2 DON, V2 Assistant Director of Nursing (ADON) and V29 Activity Director, notified vendors and resident representatives of the required PPE while in the facility. 6. On 5/13/21 V2, DON, re-educated facility staff on infection control, PPE and transmission based precautions. 7. On 5/18/21 V2, DON, and V3, ADON, re-educated staff on the steps to take when non-compliance of resident mask/facial covering is observed outside of the resident room.

Based on observation, interview and record review the facility failed to provide behavioral health care services and interventions for one of five residents (R30) reviewed for behaviors in the sample of 54. This failure resulted in R30 expressing feelings of worthlessness, recurrent thoughts of wanting to die and expressions of emotional pain. Findings include: Facility Policy/Behavioral Health Services dated 3/21/21 documents: The facility will develop and implement person-centered Care Plans that include and support the behavioral health care needs identified in the comprehensive assessment. The facility will develop individualized interventions related to the resident's diagnosed condition. Facility Policy/Behaviors of Threat to Harm Others or Themselves (undated) documents: Residents who are observed or voice a threat to others or themselves will have the following carried out: Resident will be immediately placed on increased supervision to ensure safety to themselves or others. If (Psychiatric) services unavailable, resident is to remain on increased supervision until a licensed practitioner (APRN/Advanced Practice Nurse Practitioner, PA/Physician Assistant, Physician) can evaluate resident to determine risk to harm themselves or others. Social Service Director Job Description (undated) documents: Essential Job Functions: Develop a social history, social assessment and care plan which identifies status, pertinent problems and needs of the resident. Establish realistic goals to be accomplished and the specific action to be taken toward resolution of problems and/or needs of each resident. R30's Medical Record documents that R30 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R30's Progress Note dated 8/5/20 documents that (R30) is a 1:1 who was transported by private vehicle: alert and oriented. R30's Medical Record did not contain documentation to indicate how R30 came to be transferred from an out of state Care Center to the current facility on 8/5/20. On 5/18/21 at 12:10pm V5, SSD (Social Service Director) stated that there is not any other admission information in R30's medical record to indicate why R30 was transferred here. V5 stated that (on 5/18/21), R30 told her that he came from out of state but didn't know why he was here. V5 stated that a Social Service admission assessment should have been done and didn't know why it wasn't. R30's Comprehensive assessment dated [DATE] documents that R30 is cognitively intact, able to understand and be understood. R30's Progress Note dated 9/29/20 at 9:03am indicates R30 verbalized to Physician that he will no longer take any of his medications. R30's Progress Note dated 10/7/20 at 1:09pm indicates all of R30's medications have been discontinued due to non-compliance and per R30's request (including antidepressant medication). R30's Progress Note dated 12/2/20 at 5:34pm indicates R30's family was coming to accept (R30's) depression is chronic and severe. On 5/11/21 at 12:30pm, R30 was observed lying in bed with brown stains and splotches all over bath blanket covering R30 as well as bottom sheet of mattress. R30's room was dark with no lights on and the curtains completely closed. At that time, R30 stated that he was depressed. R30 stated he was constantly sad and further stated, I want to cry myself to sleep. I sleep too much. R30 stated that he feels hopeless. R30 stated he has family nearby but doesn't get to see them. R30 stated he didn't know what the brown spots were on the linens. (Brown stains were later confirmed by V15, CNA (Certified Nurse Assistant) as feces.) R30 offered his journal stating, Do you want to look at what I'm writing? R30's notebook/journal contained handwritten notes about feeling depressed, lonely and missing his family including: The pain is there, I feel it. Why can't you? Please help it stop. I can't stand it. I want to die. I'm so alone I have massive depression, my son lives nearby but rarely visits! If only I could die, If only I could. To think I went to war, was wounded and lost body parts, got a few awards and wound up here? On 5/12/21 at 9:40am, R30 was again in a darkened room, curtains closed and lights off and stating that he feels depressed and wrote more about it in his notebook. R30 stated that he wishes he was married and is lonely. On 5/13/21 at 1:00pm V5, Social Service Director stated that about a couple weeks ago R30 asked for pencils and paper, however she was unaware R30 had been keeping a journal about his Depression. At that time, R30 allowed V15 to read his journal and after reviewing the journal, V15 stated that she was unaware of the extent of R30's Depression and acknowledged that R30 should be seeing a Psychologist or therapist. V15 stated that there should have been a Care Plan addressing R30's Depression and refusal of all medications. R30's current Care Plan did not address R30's Depression or his refusal to take any and all medications. R30's Social Service Progress Note dated 5/13/21 at 4:27pm documents that R30 shared his journal. These notes document that R30 writes that he feels he has massive depression. Note indicates that R30 is a Veteran and may be able to talk with a therapist at the VA (Veterans Administration) or in a private practice. Will continue to monitor and encourage to go outside. On 5/14/21 at 10:40am V5, SSD stated I went to see (R30) yesterday but he was sleeping both times. I guess I should've notified his nurse that he wrote that he wanted to die. Social Service Note dated 5/14/21 at 11:10am documents that V5, SSD spoke with R30 about the entry in his journal I want to die. The Social Service Note documents that R30 stated he did not have a plan and agreed to talk to a therapist. This note indicates V5 notified R30's assigned nurse that R30 needed to be monitored night and day. R30's Nursing Progress Note dated 5/14/21 at 11:30am indicates 1:1 staff member placed with (R30) at this time. R30's Nursing Progress Note dated 5/14/21 at 1:00pm indicates R30 stated he felt depressed when asked about his mood. R30 stated yes when asked if he felt suicidal. Note indicates V2, DON (Director of Nursing) offered a local hospital evaluation to which R30 responded he would like to try. Note indicates R30 is 1:1 at bedside. R30's Progress Note dated 5/14/21 at 8:44pm indicates R30 sent to local hospital, returned with recommendation for outpatient follow-up and medication review. Hospital emergency room note dated 5/14/21 at 7:53pm indicates R30 stated came to hospital because feeling depressed and R30 acknowledged having thoughts of harming himself. R30 admitted to to having suicidal thoughts because life is not worth living. On 5/19/21 at 9:00am V2, DON (Director of Nursing) stated that she would have sent R30 to the hospital for evaluation immediately after reading R30's journal. V2 stated she didn't know why V5 didn't notify nursing right away. R30's Geriatric Depression Scale dated 5/14/21 indicates R30 scored 11. Assessment indicates Scores greater than 10 are almost always depression. On 5/14/21 at 1:00pm, V5, SSD stated that this is the first Geriatric Depression Scale she's ever done and that she didn't know she was supposed to be doing them. V5 stated that with a score like that a resident should be referred to a therapist, DON should be notified and referral to Physician/Psychologist. On 5/19/21 at 9:45 am, V5, SSD stated I don't know why I didn't call on the (May)13th. V5 stated that she did notify (R30's) nurse to keep an eye on R30, however I did not tell the nurse about R30's statements of wanting to die. V5 stated that she needed to contact the VA about R30's veteran status because there is nothing in R30's chart that says R30 is a veteran. V5 stated that she took it from (R30's) writings that it was definite that he was a Veteran. V5 stated that Social Service should know if a resident is a Veteran when they are admitted . V5 also stated that if R30 had a plan (to harm himself), then she definitely would have called the doctor for an evaluation. V5 stated, Going forward, I understand I should have taken action sooner. V5, SSD reviewed R30's journal on 5/13/21 and did not notify the Physician or nursing of R30's statements of wanting to die and did not place R30 on immediate supervision. R30 was not placed on supervision until 5/14/21 when V2, DON initiated 1:1 supervision, notified R30's Physician and sent R30 to the hospital for evaluation.

Based on interview and record review, the facility failed to provide appropriate staff assistance and safety measures to prevent an injury during an assisted transfer for one of three residents (R2), reviewed for transfers, in a sample of three. This failure resulted in R2 sustaining a laceration requiring sutures. FINDINGS INCLUDE: The facility policy, Resident Transfers, dated 01-13-2006 directs staff, The facility will assess the resident to determine the safest method of transfer as a component of activities of daily living. The method of transfer will be noted in the Resident's Care Plan and on the CNA (Certified Nursing Assistant) Care Plan Guide to communicate transfer status. Safety with transfers must be a priority. The facility Preliminary Investigation Report, dated 6/18/19 documents, (R2) with thin, fragile skin was being transferred by (V3/CNA) (Certified Nursing Assistant) from bed to the (wheel) chair when (R2's) shin caught the wheelchair latch and (R2) sustained a laceration to the mid shin. (R2) was transferred to the ER (emergency room ) for treatment. R2's (facility) Face Sheet, dated 3/7/2018 includes the following Diagnoses: [REDACTED]. R2's Minimum Data Set Assessment, dated 6/13/19 documents that R2 requires total dependence on two staff members (Section G0110) for all transfers. R2's C.N.A. Care Plan Guide documents that at the time of R2's injury, R2 required the assistance of two staff members for all transfers. R2's Care Plan, dated 11/30/18 includes the following care plan problems: (R2) requires extensive assist with ADLs (Activities of Daily Living) and transfers. Also included are the following interventions: Transfer with staff assist. See Care Card (Care Plan Guide). R2's hospital Emergency Department (ED) Notes, dated 6/18/19 document, (R2) presents with left leg laceration. (R2) presents to ED today for evaluation of left lower leg laceration. (R2) lives at (facility) and (R2) was being transferred from the bed to the wheel chair when (R2's) leg got caught between the foot rest and gave (R2) a laceration to (R2's) left leg. 11 CM (centimeter) in length, V-shaped laceration, subcutaneous depth. Three sutures were placed to the lateral aspect of the v-shaped (wound) and four sutures to the medial aspect. The point of the V shape was closed with steri strips. On 7/15/19 at 11:52 A.M., V3/Certified Nursing Assistant (CNA) stated,I was transferring (R2) with on 6/18/19, around 5:00 in the evening from (R2's) bed to (R2's) wheel chair, for supper, when something went wrong and (R2's) left leg was injured. (R2) had a large skin tear, down to the muscle. I don't remember what (R2) cut (R2's) leg on. I did not use a gait belt. (V4) (Certified Nursing Assistant) was in the room with me, but (V4) didn't help me. I did the transfer by myself. At that same time, V3/CNA stated that R2's wheel chair foot pedals were not removed from R2's wheel chair before V3 completed the transfer for R2. On 7/15/19 at 2:23 P.M., V5/Licensed Practical Nurse (LPN) stated, I was (R2's) nurse, the night (R2's) leg was injured. (V4/CNA) was coming out of(R2's) room, as I was walking down the hall. She said (R2's) leg was cut. (V3/CNA) was in the room and said he had transferred (R2) by himself, not using a gait belt or the (sit-to-stand) lift, like (V3) was supposed to. The foot pedals were still on the wheel chair and it looked like (R2) caught (R2's) leg on that. The cut was bleeding a lot, it was very deep. The (previous) DON was in the room with me, helping to apply pressure and another nurse called 9-1-1 to get (R2) to the hospital. On 7/16/19 at 8:20 A.M., V9/Physical Therapy Assistant and Rehab Director stated, At the time of (R2's) injury, (R2) was a (sit to stand) lift. Residents who are partial weight bearing can use a (sit to stand) lift. During a transfer with a (sit to stand) lift, the wheel chair would be positioned next to the bedside, two staff members should always provide hands on assistance and the wheel chair pedals should be removed from the wheel chair, to prevent injury to the resident. A belt is applied to the resident's waist and the lift is activated. Once the resident is seated in the wheel chair, then the foot pedals are applied. Staff are instructed to never perform a lift transfer with the foot pedals attached to the wheel chair. They are only to be attached once a resident is seated in the chair. Due to (R2's) injury to (R2's) leg and (R2's)declining physical condition, (R2) is now a total mechanical lift. The facility Final Investigation Report, dated 6/24/19 documents, (R2) was transferred from the bed to the wheelchair inappropriately when (R2) caught (R2's) leg on the locking mechanism of the foot pedal. (R2) was not transferred from (R2's) bed to (R2's) wheel chair appropriately and therefore sustained (an) injury. Upon interviewing (V3/CNA), (V3) acknowledged he understood (R2's) transfer status and did not follow policy and procedure, therefore causing (R2's) injury.

Based on observation, interview and record review the facility failed to ensure four residents (R4, R5, R7, R8) of four residents reviewed for mental and verbal abuse remained free from such abuse. This failure caused residual emotional distress to R4 and R5. Findings include: Facility Policy/Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated (YEAR) indicates: Residents will not be subjected to abuse by anyone. - Verbal Abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance - regardless of their age, ability to comprehend or disability. - Mental abuse includes but not limited to humiliation. - It is the policy of this center that each resident will be free from abuse. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the center. No abuse or harm of any type will be tolerated. 1. POS (Physician order [REDACTED]. MDS/BIMS (Minimum Data Set/Brief Interview for Mental Status) dated 7/30/18 indicates R1 scores 15/15, is alert and cognitively intact. MDS indicates R1 has an indwelling urinary catheter. On 9/28/18 at 10:55am R4 stated that (on Monday 9/24/18) an Agency CNA (V10) was getting her into the shower chair and her catheter was hooked to the mechanical lift. R4 stated that the catheter pulled and hurt and she told V10 that she had a catheter. R4 stated that V10 responded by stating I've been an Aide for [AGE] years - I know you have a catheter. R4 then told V10 that she didn't care how long she had been an Aide, it hurt. R4 stated that the CNA (Certified Nursing Assistant) responded Well, I don't care how long you haven't walked. R4 stated that the CNA continued on with the shower and it was the worst shower she ever had. R4 stated that she told V2, DON yesterday (9/27/18) about V10. R4 stated that it made her angry and that she felt worthless by the way she was treated by V10. R4 started crying part way through recalling the incident and continued tearful throughout the interview. Preliminary Incident Investigation dated 9/27/18 and Final Investigation dated 10/2/18 indicate on the morning of 9/24/18 V10, CNA was transferring R4 with a mechanical lift and when V10 started moving the lift away from R4, R4 felt pain and quickly reminded V10 that she had a catheter and that V10 forgot to move the bag. V10 responded by stating she had been a CNA for [AGE] years. R4 then told V10 she didn't care how many years she had been a CNA, to which V10 replied I don't care how long it's been that you haven't walked. Preliminary Investigation indicates that R4 cried when reported to (V2) as her feelings are hurt. Both Investigations indicate V10 had not worked at the facility since 9/24/18 and was terminated on 9/27/18 and not allowed to return to the facility. On 10/2/18 at 3:00pm V2, DON stated that R4 is an emotional person and was tearful recalling events that took place (9/24/18). On 10/3/18 at 12:50pm V14, Social Service Director stated that R4 is a quiet person, pleasant, sensitive and emotional and her feelings are hurt easily. V14 stated that she followed up with R4 the day after it was reported but not since. Care Plan Addendum dated 10/3/18 indicates R4 is at risk for residual effects related to emotional distress. 2. POS dated 9/2018 indicates R5 is [AGE] years old and was admitted to the facility 12/14/17 with [DIAGNOSES REDACTED]. Quarterly MDS/BIMS dated 9/24/18 indicates R5 scores 12/15; requires extensive assist of two staff with transfers and toileting. On 9/28/18 at 11:15am R5 stated that she had a situation yesterday with staff and she reported it to a nurse. R5 stated that she came back from [MEDICAL TREATMENT] (on 9/27/18), felt weak and the CNA (V11) wouldn't help her go to the bathroom. R5 stated that she could hardly stand up and V11 made her feel bad because she couldn't do more to help. R5 stated that V11 just left her sitting on the side of the bed and never came back. V11 stated that she was upset and just laid herself back on the bed because she could hardly sit up. Final Investigation Report dated 10/2/18 indicates R5 stated that V11 left her alone on the side of the bed when R5 needed assistance. Report indicates R5 had been to [MEDICAL TREATMENT] earlier that day and was weak and tired. R5 stated that V11 tried to transfer her but because she was weak and couldn't help much, V11 became frustrated and just left R5 and walked out of the room. Report indicates another CNA and V13, LPN (Licensed Practical Nurse) found R5 lying perpendicular on her bed, crying, very upset and needing assistance. Report indicates V11's statement admitted that she just left R5 and expressed that she felt R5 was just trying to be difficult and not helping. V11 written statement dated 9/27/18 indicates V11 attempted to get R5 up three times from the bed to the chair and after the third time she told R5 When you're ready to help me, I'll help you. Investigation indicates R5's story very consistent with all interviews and R5 tearful upon recall. Investigation indicates V11 was terminated from employment on 9/27/18. On 10/3/18 at 11:10am V13, LPN stated that he had just come out of another residents room on (9/27/18) and observed R5 lying perpendicular across the bed, on approach saw R5 was crying, upset and asking for help. V13 stated that R5 told him that V11 had been assisting her, became upset and left her. V13 stated that R5 had [MEDICAL TREATMENT] that day and requires more assistance due to being weak. V13 stated that V11 just left R5 sitting on the bed, didn't go to find any other staff for help. V13 stated that he and another CNA helped get R5 positioned correctly in bed, attended to her needs then immediately removed V11 from resident care until V1, Administrator arrived. V13 stated that R5 seemed upset and withdrawn the remainder of the evening. V13 stated that R5 is an accurate historian and fully oriented. On 10/3/18 at 1pm V14, Social Service Director stated that she talked to R5 the day after the incident occurred and that R5 became tearful during the conversation when recalling the events. Care Plan Addendum dated 10/3/18 indicates R5 at risk for residual effects to emotional distress. 3. Report of Serious Incident/Accident/Final Report dated 7/19/18 indicates: Neglect was evidenced by the refusal to perform care for residents and inappropriate remarks made by Agency CNA (V12). Report indicates (on 7/15/18) V12 responded to resident call lights, walked into their room and shut off the call light and refused to care for the resident. Investigation indicates V12 was terminated on 7/15/18 and not allowed back to the facility. On 10/2/18 at 11:15am V6, CNA stated that (on 7/15/18) she assisted R6 onto the toilet and was then going to assist R7 off the toilet because she knew her call light was on. On the way to help R7, she saw R7's light was off and saw V12 coming from R7's room. V6 asked V12 if she had helped R7 and V12 responded no, she just turned off the light and said she can sit. V6 stated that V12 stated I can't stand her, referring to R6 and R7 as V12 walked away. V6 stated that she immediately went to R7 to get her off the toilet. 4. On 10/2/18 at 11:15 am V6, CNA stated that she asked V12 to assist her in incontinent care for R8 who had a bowel movement. V6 stated that V12 was making remarks out loud while changing R8 such as You smell. That smells awful. I can't stand it. V6 stated that R6 wasn't saying anything, but had a sad look on her face. V6 stated that she knew it was abuse and told a manager who immediately called V1, Administrator and V12 was removed from the facility. Quarterly MDS/BIMS dated 9/17/18 indicates R8 is severely cognitively impaired, is totally dependent on staff for toileting/incontinent care. R6 and R7 were seen in the hallway on 9/28/18. Neither R6 or R7 could recall events that occurred in July. On 9/28/18 at 2:15pm R8 was seen in her room. R8 did make eye contact, however did not answer questions or engage in conversation. On 10/3/18 at 12:55pm V14, Social Service Director stated that R8 cannot converse and can barely answer questions. V14 stated that she was not aware until recently about the incident that took place (7/15/18). V14 stated that she would have followed up with R8 if she had known what happened. V14 stated she should be notified of residents that make allegations of abuse or incidents when residents are abused.

Based on interview and record review, the facility failed to notify the physician with a change of condition, obtain a STAT lab draw, report abnormal laboratory results, and to transfer to the emergency room for one of one resident (R7) reviewed for physician notification in the sample of 52. This failure resulted in R7 being hospitalized with the [DIAGNOSES REDACTED]. Findings include: The facility's Change of Condition Reporting policy, dated 2/2013, documents, The facility will notify the resident's physician and the resident's representative whenever: There is significant change in the resident's health, mental or psychosocial status; There is a change in the resident's condition that although not significant is prudent to report using good nursing judgment; The resident is to be transferred or discharged . The facility's Laboratory Agreement, dated 4/8/2015, documents, The laboratory company will provide STAT (life threatening situation) service for clinical lab services 24 hours per day, 365 days per year. Laboratory STAT testing will be reported within five hours of laboratory notification. The facility's Obtaining Lab Specimens policy, dated 11/1998, documents, Document the collection of the specimen and the resulting findings in the nurse's notes, as well as physician and family notification of any abnormal results. R7's Nurse's notes, dated 2/9/18 at 2:00 a.m., document, R7 has been shaky and weak the past couple of nights. Color pale. Strong smelling urine and seems increasingly confused. R7's Nurse's notes, dated 2/9/18 at 6:45 a.m., document, R7's son requested a STAT Hemoglobin and Hematocrit. Dr notified. Orders written. STAT lab called into laboratory company. On 2/22/18 at 9:45 a.m., V8 (Certified Nursing Assistant) stated, We (V8 and V13 (Certified Nursing Assistant) reported to (V9 Licensed Practical Nurse) that (R7) wasn't acting herself before breakfast, then three additional times. (V9) kept telling us (R7) probably needs a blood transfusion. After breakfast, (R7) had a black tarry stool. We reported that to (V9). Later that morning, (R7) was dry heaving when we took her to the bathroom, and we reported that to (V9). On 2/22/18 at 12:05 p.m., V13 stated, Right away in the morning (2/9/18), (R7) is normally pretty independent and she couldn't stand or barely sit up on her own. We assisted her to the toilet and cleaned her up. I reported this to (V9) and (V9) said, 'Yeah the 3rd shift nurse told me she needs a transfusion. She's fine.' A little later (R7's) call light was on and I smelled something. So I told (R7) we needed to go to the restroom. Her skin color was yellow, and she was incontinent of black tarry stools all over in her clothing. She's never incontinent. I reported this to (V9) again, and (V9) told me, 'Yeah she needs a transfusion.' (R7) was weak all day, and didn't want to come out of her room. She is normally out and about social with activities and meals, and she wasn't herself. On 2/22/18 at 12:55 p.m., V4 (Certified Nursing Assistant) stated, (R7) wasn't feeling well. She didn't look good, and she had black tarry stools. Myself and (V13) told (V9) twice that day (2/9/18) that something was wrong with (R7) but (V9) never would do anything. R7's Nurse's notes, dated 2/9/18, document at 8:45 p.m. Received call from laboratory, R7's Hemoglobin of 3.7; at 8:55 p.m. 911 called; at 9:04 p.m. R7 left the facility by ambulance. R7's Laboratory report, dated 2/9/18, documents that a Hemoglobin and Hematocrit level were drawn on 2/9/18 at 5:27 p.m., received at 7:17 p.m., and the critical values of the Hematocrit of 14.9 (normal 35-46) and Hemoglobin of 3.7 (normal 12-15.5) were reported to the facility by fax at 9:43 p.m. R7's Nurse's notes, dated 2/9/18, have no documentation of R7's physician being notified after 6:45 a.m. with R7's change of condition symptoms, the delay in STAT lab draw, the abnormal laboratory results, nor when R7 was transferred to the emergency room . On 2/22/18 at 10:30 a.m., V9 confirmed that R7 symptoms of black tarry stools, weak and slow were reported to her by other staff members, and that she did not report these symptoms to the physician. V9 also confirmed that R7 had an order for [REDACTED]. R7's Emergency Department to Hospital Admission, dated 2/9/18, documents that R7's reason for admission was Septic Shock and [MEDICAL CONDITION] due to Gastrointestinal blood loss. R7's Hospital History and Physical, dated 2/10/18, documents, R7 presents with low hemoglobin and worsening confusion. The History and Physical also documents, R7 was brought to the emergency room and her Hemoglobin was 4.1 with [MEDICAL CONDITION] and urinalysis with a possible urinary tract infection. R7 got short of breath and hypoxemic and was started on [MEDICAL CONDITION] and admitted to the intensive care unit for evaluation and treatment. Also documented was, Principle problem: Severe [MEDICAL CONDITION] with hemocult positive stool. Transfusing packed red blood cells. On 2/22/18 at 1:30 p.m., R7 stated, I was very sick the day I went into the hospital. I don't remember anything that day I just know I was very sick. On 2/21/18 at 12:15 p.m., V1 (Administrator) stated, During that day (2/9/18) that morning a STAT lab was ordered for (R7) and her condition was changing throughout the day. It was reported to (V9) that (R7) was weaker and having black tarry stools. (V9) should have done something about this. Had she taken care of (R7) correctly she would have notified the physician and sent (R7) out earlier instead of the second shift nurse sending her out. V1 also stated, (V9) should have notified the physician of (R7's) change in condition and that her laboratory values had not been drawn. (V15 Registered Nurse) should have notified the physician when she received the critical lab result and when she sent (R7) to the emergency room . On 2/22/18 at 11:30 a.m., V7 (Medical Director) stated, I was notified at 2:00 a.m. and 6:45 a.m. regarding (R7's) change in condition, and I ordered a STAT Hemoglobin and Hematocrit with the last phone call at 6:45 a.m. A STAT lab should be drawn within a few hours not almost twelve hours later. If a STAT lab draw is delayed I would have them transferred to the emergency room to have the lab drawn. I should be notified that the laboratory is delayed, and I wasn't. If the nurse would have notified me of the new symptoms of black tarry stools I would have insisted (R7) be transferred to the emergency room much earlier than 9:00 p.m. I should have been notified of these changes and again I wasn't. I also wasn't notified of her critical laboratory value or that she was sent to the emergency room .

Based on observation, interview and record review, the facility failed to develop and implement a care plan to address a resident's skin condition for one of four residents (R4) reviewed for care plans, in a sample of 52. This failure resulted in R4 developing (2) unstageable pressure wounds and (1) stage two pressure wound. FINDINGS INCLUDE: The facility policy, Baseline Care Plan, dated (revised) 10/2017 directs staff, To ensure a plan of care is available for all residents until their comprehensive interdisciplinary care plan is completed, a 'Baseline care Plan' will be initiated within 48 hours of admission and will include the instructions needed to provide effective and person centered care and is developed based on relevant diagnoses, medical conditions and other physical or psychosocial needs. Personalize the baseline care plan so it reflects as accurately as possible the resident's conditions and care needs. Make changes, updates , additions or deletions to the Baseline Care Plan as needed based on changes of condition, new information regarding care needs, new physician orders, ect. until the Comprehensive Interdisciplinary Care Plan is completed. R4's hospital Physician Transfer Order Report, dated 11/20/17 documents that R4 was transferred to facility with the following Diagnosis: [REDACTED]. Also included are the following physician orders: Non-weight bearing to right extremity. Change dressing on post-op (operative) day 3 to [MEDICATION NAME]/[MEDICATION NAME]. (MONTH) shower with this dressing on. Change dressing as needed for soilage. Do not bend the knee. Brace on and locked in extension. R4's (un-signed) facility Admission Nursing Assessment, dated 11/20/17 documents right leg brace and under Skin General Condition, Pale, Dry, Warm. This same Assessment indicates a Surgical repair site to the top of the right knee. There is no documentation to indicate any pressure wounds upon admission to the facility. R4's Pressure Ulcer Risk Assessment, dated 11/20/17 documents that R4's skin risk as a 17. A score of 9-15 = Mod (moderate) risk. Implement appropriate Preventative Protocols-See reverse side of form. This same form (reverse side) directs staff, Check all appropriate interventions and indicates (by check mark), Turn and reposition at frequent intervals/ as necessary. Utilize pressure redistribution mattress and w/c (wheel chair) cushion. Monitor areas of pressure under splints/ braces. R4's Care Area Assessment: Pressure Ulcer, dated 12/11/17 and signed by V3/Licensed Practical Nurse/Wound Nurse, documents, At risk for pressure ulcer due to functional limitations requiring staff assistance for mobility, position changes. Proceed to Care Plan. On 2/21/18 at 10:30 A.M., V14/Licensed Practical Nurse (LPN) removed the dressings from R4's skin and revealed a 1.5 CM (centimeter) X 1 CM, Stage 2 pressure wound to the right outer ankle, a 2.5 CM X 1.75 CM, Unstageable pressure wound to the right inner knee and a 2 CM X 0.5 CM, Stage 2 pressure wound to the coccyx. At this same time, V14/LPN stated, I don't know where (R4)'s care plan is. (R4) doesn't have one. On 2/21/18 at 11:20 A.M., V17/Care Plan Coordinator stated, (R4) did not have an admission care plan. When I went to the (care plan) books to get (R4)'s care plan yesterday, (R4) did not have a current care plan. I don't know why (R4) doesn't have a care plan. Staff are supposed to use the care plan so they know how to take care of a resident. On 2/22/18 at 9:50 A.M., V3/Wound Nurse stated, (R4) does not have a care plan for (R4)'s pressure ulcers. (R4) should have one to tell the staff what to do for (R4)'s wounds.

Based on observation, interview and record review, the facility failed to assess a resident's skin condition (R3 and R4), failed to administer a physician-ordered skin treatment (R3), failed to monitor a resident's skin condition (R3 and R4) and failed to develop a care plan for an at-risk resident (R4). Two (R3 and (R4) of three residents reviewed for pressure ulcers in a sample of fifty two. These failures resulted in R3 developing multiple avoidable Stage 2 pressure ulcers and R4 developing avoidable pressure ulcers, including two unstageable pressure ulcers and a stage 2 pressure ulcer. FINDINGS INCLUDE: The facility policy, Skin Care: Pressure Ulcer/Wound Management, dated (revised) 10/04 directs staff,To promote healing of pressure ulcers, stasis ulcers and other wounds, (the facility) will use standardized protocols or follow physician's specific orders for wound care. Optimal wound management will include: Assessment of skin and wound. Use of standardized protocols. Regular reassessment to monitor effectiveness of interventions. The nurse will: Do a complete skin assessment of each new guest upon admission to identify any wounds. Document the size and description of the wound in the nurse's notes. Initiate a wound documentation form, identifying the type of wound, the size, the location and the status of the wound. Obtain orders for (an) appropriate treatment. Implement appropriate pressure ulcer prevention protocols per policy. Complete skin assessments on all guests weekly after showers or as assigned to check for new skin integrity impairment. Document results in the nurse's notes. Perform treatments as ordered. Make changes to the resident's care plan as necessary to include risk of skin integrity impairment, current skin condition, preventative measures taken and treatments. 1. R3's Physician Transfer Order Report documents that R3 was transferred to the facility from a local hospital on [DATE] after surgery from a Closed [MEDICAL CONDITION] Distal Femur. R3's other [DIAGNOSES REDACTED]. Included in this same document is an order for [REDACTED]. R3's facility Admission Nursing Assessment, dated 2/12/18, under General Skin Condition, directs staff to, In the diagram below please indicate all body marks such as old/recent scars (surgical and other), bruises, discoloring, abrasions, pressure ulcers or any questionable markings. Indicate decub (decubitus) size, depth, color and drainage. No bruises, discolorations, abrasions or decubitus ulcers are documented on R3's skin assessment. R3's Physician order [REDACTED].M. and 6:00 P.M. over excoriated buttocks, and Weekly Skin Assessment on Mondays. R3's Treatment Administration Record, dated 2/12/18 does not document the physician ordered treatment or that the facility staff completed the treatment as ordered on [DATE], 2/13/18, 2/14/18 or the morning of 2/15/18. This same Treatment Record does not document (R3) being assessed for Weekly Skin Assessments on 2/12/18 or 2/19/18. R3's (untimed) Nurse's Progress Notes, dated 2/15/18 document, (3) Stage 2 areas with excoriation of whole buttocks. Bruising of buttocks and abdomen, also of right leg from fall at home. R3's facility Wound Documentation (3 documents) dated 2/12/18 documents, #1. Pressure wound to left buttocks, Stage 2, 1.5 CM (centimeter) X 0.5 CM, scant sero-sanguinous exudate with redness to the peri-wound area. #2. Pressure wound to left buttocks, Stage 2, 1 CM X 1 CM, scant sero-sanguineous exudate, with episodic pain and redness to peri-wound area. #3. Pressure wound to right buttock, Stage 2, 1 CM X 1 CM, scant to moderate sero-sanguineous exudate with redness to peri-wound area. On 2/20/18 at 1:40 P.M., V15/Registered Nurse stated, I got in Report from the hospital that (R3)'s bottom was excoriated. I did not look at (R3)'s bottom once (R3) got here on 2/12/18. I didn't have enough help and it would have taken three of us to roll (R3). (R3)'s a big lady. There wasn't any orders for a treatment to (R3)'s bottom on admission. On 2/20/18 at 1:50 P.M. V18/ Licensed Practical Nurse (LPN) stated, I took an order from the doctor on (MONTH) fifteenth for (R3)'s buttocks. (R3) had three pressure ulcers. I didn't write a telephone order for the treatment. On 2/20/18 at 1:55 P.M. V3/Wound Nurse stated, I saw (R3)'s buttocks on (MONTH) fifteenth, (R3) had three stage two pressure sores. On 2/21/18 at 8:30 A.M., V2/Director of Nurses verified that R3's Treatment Administration Record did not document the physician ordered treatment as being administered or weekly skin assessments as being performed. On 2/21/18 at 12:35 P.M., V1/Administrator stated, A nurse would be expected to complete a skin assessment on admission, document the findings, obtain a doctor's order for a treatment and document that treatment on the treatment administration record. On 2/22/18 at 11:20 A.M., V7/Physician stated, Untreated, macerated skin over a pressure area can lead to the development of a pressure wound. 2. R4's Physician order [REDACTED]. This same document includes the following physician's orders [REDACTED]. (MONTH) do touch down weight bearing on right side to maintain balance if needed. Change dressing on post op (operative) day 3 to [MEDICATION NAME]/[MEDICATION NAME]. (MONTH) shower with this dressing on. Do not bend the knee. Brace on and locked in extension. R4's facility (un-signed) Admission Nursing Assessment, dated 11/20/17 at 4:00 P.M. includes the following documentation under Skin General Condition, pale, dry, warm. This same document instructs the user, In the diagrams below please indicate all body marks such as old/recent scars (surgical and other), bruises, discoloring, abrasions, pressure ulcers or any questionable markings. Indicate decub (decubitus) size, depth, color and drainage. The anterior view of the diagram includes, Pacemaker scar (upper left chest), IV (intravenous) site X2 (left lower arm) and Surgical repair site (right knee). The posterior view of the diagram is blank. The diagram does not include any areas noted for decubitus ulcers. A right leg brace is documented under Supportive Devices Used. R4's Pressure Ulcer Risk Assessment, dated 11/20/17 documents that R4's skin risk as a 17. A score of 9-15 = Mod (moderate) risk. Implement appropriate Preventative Protocols-See reverse side of form. This same form (reverse side) directs staff, Check all appropriate interventions and indicates (by check mark), Turn and reposition at frequent intervals/ as necessary. Utilize pressure redistribution mattress and w/c (wheel chair) cushion. Monitor areas of pressure under splints/ braces. R4's Treatment Administration Record (TAR) dated 11/20/17 includes the following physician's orders [REDACTED]. R4's Physical Therapy Evaluation and Plan of Treatment, dated 11/21/17 documents under Assessment Summary, (R4) is a pleasant and cooperative [AGE] year old who presents to this facility s/p (status [REDACTED]. (R4) (is) at a w/c (wheel chair) level and unable to ambulate secondary to NWB status. Due to documented physical impairments and associated functional deficits, (R4) is at risk for [MEDICAL CONDITION] ([MEDICAL CONDITION], falls, further decline in function, immobility, [MEDICAL CONDITION] and pressure sores. R4's Minimum Data Set (MDS) Assessment, dated 11/29/17 documents under Activities of Daily Living (ADLs) that R4 requires, extensive assist of 2 staff members for bed mobility and transfers. This same assessment documents R4's Risk of Pressure Ulcers as, (This resident) is at risk of developing pressure ulcers. And, (This resident) does (not) currently have one or more unhealed pressure ulcers at Stage 1 or higher. R4's Care Area Assessment: Pressure Ulcer, dated 12/11/17 and signed by V3/Licensed Practical Nurse/Wound Nurse, documents, At risk for pressure ulcer due to functional limitations requiring staff assistance for mobility, position changes. Proceed to Care Plan. R4's facility Treatment Administration Record, dated (MONTH) (YEAR) documents facility staff only performed a Weekly Skin Assessment on R4's skin on 12/9/17 and 12/23/17 by staff initializing as complete. There is no documentation of moisture, color, temperature, integrity or turgor. There is no staff documentation on 12/2/17 and 12/16/17 that R4's physician ordered skin assessment was completed. R4's (unsigned) 12/9/17 Shower Record/Skin Audit documents, Reddened areas (pressure). This same form documents, Slightly red between cheeks and has an arrow pointing to the coccyx/buttocks area. This form directs facility staff, If New condition, Nurse must notify Physician and Responsible Party. Secure Treatment. The form gives no indication that the physician or responsible party were notified or that a treatment for [REDACTED]. R4's Nurse's Progress Notes, dated 12/20/17 document, 12 pm Two open areas noted to (R4)'s buttocks. One on (R4)'s coccyx measuring 2 CM (centimeters) X 1.2 CM. The other open area on the left buttocks measuring 1.5 (CM) X 0.5 (CM). The facility Weekly Pressure Ulcer Report, dated 12/29/18 documents, (R4) Stage 2 pressure ulcer to coccyx, identified on 12/20/17. Current measurements include: 1.5 (CM) X 1.5 (CM). This same form documents (R4)'s pressure ulcer as, House Acquired. R4's (MONTH) (YEAR) Treatment Administration Record documents that no facility staff completed physician ordered weekly skin assessments for the entire month. The facility Weekly Pressure Ulcer Report, dated 1/5/18 documents, (R4) Stage 2 pressure ulcer to coccyx, 2 CM X 2 CM. The facility Weekly Pressure Ulcer Report, dated 1/19/18 documents, (R4) Coccyx pressure ulcer as UTS (unstageable). R4's Nurse's Progress Notes, dated 1/21/18 at 6:00 P.M. document, Open area noted 1 CM X 1 CM on (R4)'s right inner knee. R4's Ortho (Orthopedic) Note, dated 1/24/18 documents, (R4) has pressure ulcer on medial aspect of knee. R4's Nurse's Progress Notes, dated 1/30/18 document, New order received (for treatment) to right outer ankle. Cleanse with NS (Normal Saline), apply [MEDICATION NAME] and cover with border adhesive. R4's Wound Documentation form, dated 1/26/18 documents,Right knee 4 CM X 2 CM, 100% eschar (Unstageable) to wound bed. Pressure from brace. R4's (MONTH) (YEAR) Treatment Administration Record documents that no facility staff completed physician ordered weekly skin assessments through 2/20/18. On 2/21/18 at 10:30 A.M., V14/Licensed Practical Nurse (LPN) removed the dressings from R4's skin and revealed a 1.5 CM (centimeter) X 1 CM, Stage 2 pressure wound to the right outer ankle with a yellow eschar center; a 2.5 CM X 1.75 CM, Unstageable pressure wound to the right inner knee with thick yellow eschar and a hard, black necrotic center. A foul odor and yellow drainage were noted when the dressing was removed; and a 2 CM X 0.5 CM, Stage 2 pressure wound to the coccyx that was pink with hard, white, rolled edges. The bandage was full of stool. At this same time, V14/LPN stated, (R4)'s leg brace caused the wounds. I don't know where (R4)'s care plan is. (R4) doesn't have one. On 2/21/18 at 12:45 P.M., V2/Director of Nurses (DON) stated, We knew that brace (of R4)'s was gona be a problem. It didn't fit (R4) well when they put it on (R4). It kept bothering (R4). They (staff) were supposed to be looking at (R4)'s skin everyday. They (staff) should have charted it in (R4)'s TAR. I would call that area on (R4)'s right ankle a stage 2 pressure ulcer. The wound nurse said it was an abrasion, but it's not. At that time, V2/DON verified that R4's treatment administration records were incomplete. On 2/22/18 at 9:50 A.M., V3/Wound Nurse stated, (R4) was admitted (to the facility) in (MONTH) and should have been repositioning from side to side due to (R4) being at risk for skin breakdown. (R4) also should have weekly skin checks done by a nurse and the results should be documented on the back of the treatment record. (R4) was found with a stage two open area on (R4)'s buttocks on (MONTH) twentieth during cares. At one point the wound deteriorated until it was unstageable. I don't know who found that area on (R4)'s buttocks on (December) ninth. If we had known, there are interventions we could have started to prevent it from getting worse. (R4) does not have a care plan for (R4)'s pressure ulcers. (R4) should have one to tell the staff what to do for (R4)'s wounds.

Based on interview and record review the facility failed to ensure a physician ordered laboratory value was obtained in a timely manner for one of one resident (R7) reviewed for laboratory values in the sample of 52. This failure resulted in R7 being hospitalized with the [DIAGNOSES REDACTED]. Findings include: The facility's Lab/X-ray orders policy, dated 11/1998, documents, Radiological and diagnostic testing will be available 24 hours per day, seven days a week. The facility's Laboratory Agreement, dated 4/8/2015, documents, The laboratory company will provide STAT (life threatening situation) service for clinical lab services 24 hours per day, 365 days per year. Laboratory STAT testing will be reported within five hours of laboratory notification. R7's Nurse's notes, dated 2/9/18 at 2:00 a.m., document, R7 has been shaky and weak the past couple of nights. Color pale. Strong smelling urine and seems increasingly confused. R7's Nurse's notes, dated 2/9/18 at 6:45 a.m., document, R7's son requested a STAT Hemoglobin and Hematocrit. Dr notified. Orders written. STAT lab called into laboratory company. R7's Laboratory report, dated 2/9/18, documents that a Hemoglobin and Hematocrit level were drawn on 2/9/18 at 5:27 p.m., received at 7:17 p.m., and the critical values of the Hematocrit of 14.9 (normal 35-46) and Hemoglobin of 3.7 (normal 12-15.5) were reported to the facility by fax at 9:43 p.m. R7's Nurse's notes, dated 2/9/18, document at 8:45 p.m. Received call from laboratory, R7's Hemoglobin of 3.7; at 8:55 p.m. 911 called; at 9:04 p.m. R7 left the facility by ambulance. R7's Emergency Department to Hospital Admission, dated 2/9/18, documents that R7's reason for admission was Septic Shock and [MEDICAL CONDITION] due to Gastrointestinal blood loss. R7's Hospital History and Physical, dated 2/10/18, documents, R7 presents with low hemoglobin and worsening confusion. The History and Physical also documents, R7 was brought to the emergency room and here Hemoglobin was 4.1 with [MEDICAL CONDITION] and urinalysis with a possible urinary tract infection. R7 got short of breath and hypoxemic and was started on [MEDICAL CONDITION] and admitted to the intensive care unit for evaluation and treatment. Also documented was, Principal problem: Severe [MEDICAL CONDITION] with hemocult positive stool. Transfusing packed red blood cells. On 2/22/18 at 1:15 p.m., V2 (Director of Nursing) stated that a STAT lab value should be drawn within two to four hours, and if it doesn't get done in that time frame the nurses should call the laboratory again and see where the phlebotomist is. V2 also stated that the nurses can draw the lab value themselves and take it to the laboratory or send the resident to the emergency room . On 2/22/18 at 11:30 a.m., V7 (Medical Director) stated that he was notified at 6:45 a.m. on 2/9/18 regarding R7's change in condition and he ordered a STAT Hemoglobin and Hematocrit. V7 also stated a STAT lab should be down within a few hours not almost twelve house, and if a STAT lab draw is delayed he would have had the facility transfer the resident to the emergency room to have the lab drawn.

Based on observation, interview and record review, the facility failed to cover a stage two pressure ulcer and failed to perform incontinence care to prevent contamination of a stage two pressure ulcer for one of three residents (R3) reviewed for pressure ulcers in a sample of six. FINDINGS INCLUDE: On 4/18/16 at 1:05 P.M., E3 and E12 Certified Nursing Assistants (CNAs) and E13 Rehab/Restorative Aid prepared to transfer R3 from the wheel chair to bed via a mechanical lift. After transferring R3, E3 and E12/CNAs, removed R3 pants and adult incontinence brief. There was a large amount of brown stool in the brief. A 2 CM (centimeter) X 1 CM X 0.4 CM deep pressure ulcer was present to R3's coccyx. The pressure ulcer had a pink wound bed with a white macerated area surrounding the wound. No dressing was in place, covering the wound. Using a disposable wipe, E3/CNA cleaned R3's buttocks, including the pressure ulcer. Wiping the wound with the soiled cloth. E3 and E12/CNAs then applied a clean disposable incontinence brief on R3, repositioned R3's covers, handed R3 the remote control and left R3's room. R3's Pressure Ulcer Risk Assessment, dated 3/9/16 documents R3 is at High Risk for the development of pressure ulcers. R3's current Care Plan, dated 3/6/16 documents, Problems: Stage 2 Coccyx Wound. Interventions: Assess wound weekly. Monitor for signs and symptoms of infection. Provide treatment as ordered. See Treatment Administration Record. Use caution to protect area. R3's current Physician order [REDACTED]. Cover with (non-adherent dressing) and tape. On 4/18/16 at 1:15 P.M., E3/CNA stated, I didn't mean to wipe over (R3)'s bed sore with it (disposable wipe). I don't know why (R3) didn't have a dressing on (R3)'s wound. I didn't get (R3) up this morning. On 4/18/16 at 1:25 P.M., Z1/Certified Nursing Assistant (CNA) stated, I am an Agency CNA. This is my first time working here (the facility). I got (R3) up before 8:00 A.M. I don't remember (R3) having a dressing on (R3's coccyx) when we got (R3) up. Nobody told me (R3) had a pressure ulcer. On 4/19/16 at 12:50 P.M., E2/Director of Nurses confirmed (R3) should have a dressing in place to (R3)'s coccyx at all time. E2/DON also confirmed a pressure ulcer wound should not be cleaned with a soiled, disposable wipe. Despite repeated requests, E2/DON did not provide a policy for wound cleansing or application of a wound dressing.