Every finding on record at Citadel of Glenview,The

Based on observation, interview, and record review the facility failed to complete infectious screening assessment for resident started on antibiotics and formulate a care plan for its usage. The facility also failed to monitor behavior and medication side effects for resident on psychotropic medications. This deficiency affects all 4 residents (R3, R8, R123 and R129) in the sample of 25 reviewed for Unnecessary medications.Findings include: R3On 7/22/25 at 11:50AM, Observed R3 lying in bed watching TV. He is alert and oriented x 3. Reviewed R3's medical record. R3 was admitted on [DATE] with Chronic Obstructive Pulmonary, End Stage Renal disease, Dependence of renal dialysis, acquired absence of right and left below the knee amputation. Active physician order sheet indicated: Azithromycin oral tablet 500mg 1 tablet by mouth in the morning every MWF for prophylaxis PNA (Pneumonia) date 7/11/25. Infectious screening assessment for Antibiotic completed on 7/22/25 and Care plan for antibiotic usage as prophylaxis was initiated on 7/22/25 after surveyor made an inquiry. On 7/23/25 at 9:24AM, V3 ADON said she is responsible for completing infectious screening assessment when a resident receives an antibiotic ordered. V3 said, ideally prior to start of antibiotic but when it happened on weekends, she will do it on Monday. The infectious screening assessment is like McGeer Criteria. When the assessment did not meet the criteria, she will do the antibiotic time out assessment. V3 is also responsible for formulating care plan for antibiotic usage. Informed V3 R3's medical record was reviewed on 7/22/25 and noted she does not have infectious screening assessment and care plan for antibiotics usage for PNA prophylaxis. The medication was ordered last on 7/11/25. Both antibiotic assessment and care plan were initiated yesterday 7/22/25 after the surveyor made an inquiry about it. V3 said it was an oversight. She said she was on vacation for 3 weeks and just returned. R8On 7/22/25 at 12:11PM, Observed R8 eating in the dining room with her mother. R8 was admitted on [DATE] with diagnosis listed in part but not limited to metabolic encephalopathy, Acute pyelonephritis, history of UTI, Proteus mirabilis as cause of disease. Active physician order sheet indicated Trimethoprim oral tablet 100mg give 1 tablet by mouth one tine a day for prophylaxis UTI date 6/18/25. Infectious screening assessment for Antibiotic completed on 7/22/25 and Care plan for antibiotic usage as prophylaxis was initiated on 7/22/25 after surveyor made an inquiry. On 7/23/25 at 9:24AM, Informed V3 that R8's medical record was reviewed on 7/22/25 and noted R8 does not have infectious screening assessment and care plan for antibiotics usage for UTI prophylaxis. The medication was ordered 6/18/25. Both antibiotic assessment and care plan were initiated yesterday 7/22/25 after the surveyor made an inquiry about it. V3 said it was an oversight. She said she was on vacation for 3 weeks and just returned. R123On 7/23/25 at 9:04AM, Observed R123 lying on bed with Oxygen via nasal cannula. R123 said he uses his oxygen as needed for shortness of breathing. Observed R123 cough occasionally. He said he was on antibiotics last 2 weeks.R123 was admitted on [DATE] with diagnosis listed in part but not limited to Nontraumatic subarachnoid hemorrhage, Kidney transplant, End stage renal disease, Obstructive reflux uropathy. Active physician order sheet indicated: Sulfamethoxazole-Trimethoprim oral tablet 400-80mg give 1 tablet by mouth in the evening every MWF for renal transplant infection prophylaxis date 7/8/25. Infectious screening assessment for Antibiotic completed on 7/22/25 and Care plan for antibiotic usage as prophylaxis was initiated on 7/22/25 after surveyor made an inquiry. On 7/23/25 at 9:24AM, Informed V3 ADON that R123's medical record was reviewed on 7/22/25 and noted she does not have infectious screening assessment and care plan for antibiotics usage for renal transplant prophylaxis. The medication was ordered 7/8/25. Both antibiotic assessment and care plan were initiated on 7/22/25 yesterday after the surveyor made an inquiry about it. V3 said it was an oversight. She said she was on vacation for 3 weeks and just returned. R129On 7/23/25 at 9:30AM, Observed R129 sitting in the activity room. He is alert and responsive in Spanish language. On 7/23/25 at 10:05AM, V14 LPN said R129 is on psychotropic medications- Xanax, Sertraline and Zoloft for his depression and anxiety. He can be agitated and resistant to care. Reviewed R129's electronic medical records. Observed R129 did not have order for behavior monitoring/recording of occurrence of target symptoms and medication side effects. No documentation of behavioral monitoring and medication side effects every shift in Medication administration record. V14 said usually a resident on psychotropic medications is monitored for occurrence of behavior and medication side effects in MAR (Medication Administration Record). V14 said she will refer it to V2 DON and V3 ADON. R129 was admitted on [DATE] with diagnosis listed in part but not limited to Altered mental status, Insomnia, Anxiety disorder, Restlessness and agitation, Dementia, End stage renal disease. Active physician order sheet indicated Alprazolam oral tablet 0.25mg give 2 tablets by mouth every Tuesday, Saturday for anxiety. Sertraline HCL tablet 50mg give 1 tablet by mouth one time a day for depression total 75mg take with 25mg, Zoloft oral tablet 25mg give 1 tablet by mouth in the morning for depression total 75mg take with 50mg. Comprehensive care plan indicated: R129 is at risk for side effects related to use of anti-depressant and anti-anxiety medications: Interventions: Monitor /record occurrence of for target behavior symptoms ( specify pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. Monitor/document/report PRN any adverse reactions to medications- drowsiness, lack of energy, slow reflexes, change in mood/behavior/cognition, etc. On 7/23/25 at 11;23AM, V2 DON said that a resident on psychotropic medication is monitored for resident behavior and medication side effects. They have target behavior and medication side effects monitoring in the MAR (Medication Administration Record). They marked frequency of behavior occurred during shift and intervention provided. They also marked any medication side effects observed. Informed V2 of above observation made that R129 did not have behavior monitoring /recording and medication side effects in MAR for the 3 psychotropic medications he is taking. Informed V2 of above concern with R129 regarding monitoring and recording of behavior and medication side effects of psychotropic medications were not done. V2 said it was an oversight. Facility's policy on Stewardship revised December 2018 indicated: Policy statement: Antibiotics will be prescribed and administered to resident under the guidance of the facility's antibiotic stewardship program. Policy interpretation and implementation: 1. Purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. 2.If an antibiotic is indicated, prescriber will provide complete antibiotic orders. Facility's policy on Antibiotic stewardship-staff and clinician training and roles revised December 2016) indicates: Policy statement: The facility will educate and train staff and practitioners about the facility antibiotic stewardship program, including appropriate prescribing, monitoring, and surveillance of antibiotic use and outcomes. Policy interpretation and implementation: Director of Nursing (DON) and Infection Preventionist (IP): 2. The DON will monitor individual resident antibiotic regimens.Facility's policy on Antibiotic stewardship- orders for antibiotics revised December 2016 indicates: Policy statement: Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotics stewardship program in conjunction with the facility's general policy for medication utilization and prescribing.Policy interpretation and implementation: 3. Appropriate indication for use of antibiotics. Facility's policy on Antibiotic Stewardship- Review and surveillance of antibiotic use and outcomes revised December 2026 indicated: Policy statement: Antibiotic usage and outcome date will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. Policy interpretation and implementation: 1. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist or designee.2. The IP or designee will review the antibiotic utilization as part of the antibiotic stewardship program and identify specific situations are not consistent with the appropriate use of antibiotics. 4. All resident antibiotic regimens will be documented on the facility approved antibiotic surveillance tracking form. Facility's policy on Psychotropic Medication Use revised 10/23/22 indicated: Definition: Psychotropic drugs include but are not limited to antipsychotics, anti-anxiety, antidepressants, or sedative-hypnotics affect brain activities associated with mental processes and behavior. Procedure: 4. Psychotropic medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use. 15. Facility staff should be monitoring the resident behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medication for organic mental syndrome with agitation or psychotic behaviors. Facility staff should monitor behavior triggers, episodes, And symptoms. Facility staff should document the number and or intensity of symptoms and the resident's responses to staff interventions.

Based on observation, interview and record review the facility failed to treat each resident with respect , dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, and failed to provide a dignified dining experience for 1 of 3 residents observed during meal service in the resident's room for 1 of 3 resident's (R13) in a sample of 25. Findings include: On 7/23/2025 at 11:45am R13 was observed in bed with a meal tray in front of her the top lid off and a fork down in the food.On 7/23/2025 at 11:50am V20 (Certified Nursing Assistant-CNA) was observed escorting three residents to the dining area.On 7/23/2025 at 11:57am V20 said, I am (R13's) CNA, the nurse called me away to escort residents to the dining area, I'm in the process of assisting her with eating, she eats very well and needs full assistance. V20 was asked should her meal tray be uncovered while not eating. V20 said, Her food is not cold, the bottom tray is warm.On 7/23/2025 at 12:04pm V20 was observed taking the top lid off the table and removed a half-eaten sandwich from under the top lid, wrapped the sandwich in a napkin and placed it in her pocket, then proceeded to feed R13.An Order Summary Report dated 7/24/2025 indicates that R13 has a diagnosis of blindness in the left eye, hemiplegia, and hemiparesis, an order summary report dated 7/24/2025 that indicates R13 must be suctioned for oral secretions and pocketed food, a care plan dated 6/27/2025 that indicates R13 is able to eat her meal with supervision/setup assist.A facility policy: Quality of Life -Dignity Revised February 2020Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem.Policy Interpretation and Implementation1.Residents are treated with dignity and respect.

Based on observation, interview, and record review the facility failed to ensure prevention of using physical restraints to unnecessarily impede R9's freedom of movement affecting 1 of 1 resident (R9) reviewed for freedom of restraint in a total sample of 25. Findings Include:On 7/23/2025 at 12:45 PM, R9 was seated in the wheelchair with self-releasing belt applied around the chest-abdominal area. V18 (Korean Program Director) translated to R9 to demonstrate how to release the self-releasing belt. R9 was not able to remove the belt independently and was not able to follow command. V18 stated R9 is not able to release the belt on her own. On 7/23/2025 at 2:05 PM, V2 (Director of Nursing) stated self-releasing belt is removed by the resident without assistance from staff. V2 said R9 uses the self-releasing belt to prevent her from standing up. V2 said there was no restraint assessment completed for R9.Review of R9's medical records read: Initial admission Date: 11/18/2023. Diagnosis Information include Metabolic Encephalopathy, Unspecified Dementia, Unspecified Severity, with Psychotic Disturbance, Other Reduced Mobility, Lesion of Sciatic Nerve, Bilateral lower Limbs. BIMS score =4, Quarterly Assessment 4/30/2025. Order Summary Report read: Order Date: 7/22/2025, Start Date: 7/22/2025, Self-releasing belt to be applied when the resident is sitting on her wheelchair. Care Plan Report read: R9 uses a self-release belt: at risk for skin injury, date initiated 9/11/2024. Nurses Progress Note, 7/23/2025 read: Note text: Patient unable to Self-releasing belt. NP notified with orders to D/C.Policy and Procedure: Title: Physical Restraint Application, Revised October 2016Purpose: The purpose of this procedure is to provide safety or postural support of a resident to prevent injury to the resident or others when resident has medical symptoms that warrant the use of restraints.Definition: Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.Preparation: 1. Verify physician's order for the use of restraints. 2. Review the resident's care plan to assess for any special needs of the resident.Documentation: The following information should be recorded in the resident's medical record: 4. The specific reason the restraint was applied.

Based on interview and record review the facility failed to refer a resident to the appropriate state designated authority for a PASARR level 2 screening for evaluation and determination of newly evident serious mental illness related condition, for two of four residents (R12, R62) reviewed for a PASARR level 2 screening in a sample of 25. Findings include:1. On 7/23/25 at 12:23PM, V1(Administrator) said a level II PASARR was completed for R12 in 2018 and if a new mental diagnosis is added then a new level II PASARR should be completed by social services. On 7/23/25 at 12:52PM, V5 (Social Services) said in 2021 when the new diagnosis was added she was not working in the facility. V5 said she will find out if R12 needs a level II PASARR completed again. On 7/23/25 at 1:45PM, V5 said there is no level II PASARR for R12 completed after a new diagnosis and medication was added V5 said a level II PASARR should have been completed again to provide appropriate program and services to resident. An admission record indicates that R12 has a diagnosis of Major Depressive Disorder, recurrent, unspecified, bipolar disorder, unspecified dated 2/5/2021, anxiety disorder dated 8/27/2021, Paranoid Personality Disorder dated 6/10/2025. A psychotropic medication Seroquel 200 MG dated 6/18/25, Clonazepam 0.5mg dated 6/18/25. 2. On 7/23/2025 at 12:30pm V5(Social Service Director-SSD) observed with this writer, R62 has a new diagnosis of unspecified psychosis dated 4/19/2023, Delusional Disorder dated 1/13/2023 and a psychiatric medication added Risperdal 1mg dated 1/13/2023 for psychosis. On 7/23/2025 at 12:40pm V5 said that R62 should have a new PASARR level 2 completed with services and does not at this time. An admission record indicates that R62 has a diagnosis of Unspecified psychosis not due to a substance or know physiological condition dated 3/23/2023, Delusional Disorder dated 1/13/2023. A psychotropic medication Risperdal 1mg dated 1/13/2023 for psychosis. A facility Policy: admission Criteria Revised December 2016. Policy: Our facility will admit only those residents who's medical and nursing care needs can be met. 8. Nursing and medical needs of the individual with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program (PASARR) to the extent practicable.

Based on observation, interview, and record review the facility failed to ensure Preadmission Screening and Resident Review (PASARR, Level I and Level II) was conducted prior to admission affecting 2 of 2 residents (R91, R122) reviewed for PASARR in a total sample of 25.Findings Include:1. On 7/23/2025 at 12:35 PM, V19 (admission director) stated that the social service department should be the one to complete PASARR of every residents in the facility. On 7/23/2025 at 2:00 PM, V1 (Administrator) stated there was no PASARR completed for R122 prior to admission in the facility. V1 said that he is aware that PASARR needs to be done for all admissions to determine any specialized services to be provided. Review of records of R122 read; [AGE] year-old female patient initially admitted in the facility on 5/20/2022. R122 has diagnosis including Dementia, unspecified severity, with other behavioral disturbance, Unspecified psychosis not due to a substance or known physiological condition, Delusional disorder, bipolar disorder, adjustment disorder with depressed mood, Restlessness and agitation. Order summary read; Divalproex Sodium Oral Tablet Delayed Release 125 MG (Divalproex Sodium) and Mirtazapine Tablet 7.5 MG. The Care Plan report states revision 12/12/2023 Focus, R122 exhibits symptoms of rejecting/resisting care which is related to Psychiatric illness, severe mental illness, Alzheimer's disease or a related dementia; Focus, R122 demonstrates mood distress related to diagnosis of dementia or psychopathology (e.g., schizophrenia, bipolar disorder, personality disorder).2. On 7/23/2025 at 10:52AM, V1 (Administrator) stated there was no PASARR completed for R91 prior to admission. V1 stated PASARR need to be completed for all residents prior to admission to provide the appropriate services and if eligible for Nursing Home admission. On 7/23/2025 at 12:25PM, V19 (admission Director) stated PASARR need to be completed prior to resident admission. V19 said he is responsible for all new admission; however, social service is responsible for running PASARR for residents already in the facility. Review of R87 admission Record indicate an admission date of 7/6/2022. Diagnosis Information include Major Depressive Disorder, Recurrent, Unspecified, Delusional Disorders. Care Plan report state, 1/13/2025 Focus: R91 has history of behavior. Mental health factors include:Evidence of severe mental illness (i.e., active psychosis, major depression, lack of sound judgment, poor contact with reality). Poor impulse control. Lack of awareness of the full impact of committing suicide (i.e., finality of death, impact on loved ones, belief that a problem may be resolved through death). Feelings of helplessness, hopelessness; little hope that life will improve. Policy and Procedure: Policy: admission Criteria, Revised December 2016 Policy Statement: Our facility will admit only those residents whose medical and nursing care needs can be met. Procedure: 8. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program (PASARR) to the extent practicable.

Based on observation, interview, and record review the facility failed to provide nail care to dependent resident. This deficiency affects one (R129) of three residents in the sample of 25 reviewed for ADLs (Activity of Daily Living) Program. Findings include: On 7/23/25 at 9:39AM, Observed R129 sitting in the dining room. He is alert and responsive in Spanish language. V8 WCN (Wound Care Nurse) said that he is confused. R129 needs assistance with ADLs and transfers. Observed long and dirty fingernails with black matter underneath the nails. V8 said the CNA (Certified Nurse Assistant) is responsible for providing nail care as part of the ADLs program.R129 was admitted on [DATE] with diagnosis listed in part but not limited to, Altered mental status, Dependence of renal dialysis, End stage renal disease (ESRD), Chronic Obstructive Pulmonary disease (COPD). MDS/Resident assessment dated [DATE] Section GG Functional abilities GG0130 Self-care indicated: Personal hygiene marked 2 Substantial/maximal assistance (Helper does more than half the effort. Helper lift or holds or supports trunk or limbs and provides more than half the effort). Comprehensive care plan indicated he has an ADL self-care performance deficit related to activity intolerance due to ESRD, hemodialysis and COPD.On 7/23/25 at 11:23AM, Informed V2 DON (Director of Nursing) of above observation and concern. V2 said the assigned CNA is responsible for providing nail care to R129 as part of the ADL program.Facility's policy on Supporting ADLs (Activity of Daily Living) reviewed March 2018 indicates:Policy statement: Residents will provide with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Resident who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal oral hygiene.Policy interpretation and implementation:2. Appropriate care and service will be provided for residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:a. Hygiene- bathing, dressing, grooming and oral care.Facility's policy on care of Fingernails/toenailsPurpose: to clean the nailbed, to keep nails trimmed and to prevent infections.General guidelines:1. Nail care includes daily cleaning and regular trimming

Based on observation, interview, and record review the facility failed to ensure that no treatment medication is left at bedside without physician order. This deficiency affects one (R8) of three residents in the sample of 25 reviewed for Medication safety. Findings include: On 7/23/25 at 9:53AM, V8 WCN (Wound Care Nurse) and V21 Wound Tech assisted R8 to stand up from the wheelchair to perform skin check to sacral area. Observed R8's sacral area with redness. V21 Wound tech grabbed the nystatin powder bottle from the bedside table to apply. Surveyor asked if they are providing treatment to R8's sacral redness and leaving the medication at bedside. V8 WCN said the floor nurses are the one providing treatment to R8 for redness and no medication should be left at bedside. On 7/23/25 at 2:16PM, Informed V2 DON (Director of Nursing) of above observation and concern. V2 DON said that no medication should be left at bedside for safety unless order by physician. R8 was admitted on [DATE] with diagnosis listed in part but not limited to metabolic encephalopathy, Demyelinating disease of central nervous system, Cognitive communication deficit. Active physician order sheet indicated Nystatin powder apply to perineal area topically every shift for redness. She is alert and confused with BIMS (Brief interview of mental status) score of 3. Facility's policy on Storage of Medication revised April 2019 indicated: Policy statement: Th facility stores all drugs and biologicals in a safe, secure, and orderly manner.

Based on observation, interview, and record review the facility failed to place EBP (Enhanced Barrier Precaution) signage and set up for resident on dialysis. The facility also failed to clean and disinfect vital signs equipment after resident use. This deficiency affects three ( R55, R7, R129) of three residents in the sample of 25 reviewed for Infection Control Management.Findings include: 1. On 7/22/25 at 10:24AM, V2 DON (Director of Nursing) presented list of residents on EBP. R129 was not listed in the list of residents on EBP. On 7/22/25 at 11:30Am, V14 LPN (Licensed Practical Nurse) said R129 is currently on dialysis. Observed R129's room with no signage for EBP and no EBP set up outside the door. V14 said R129 should be EBP due to his dialysis. V14 said she did not realize there is no signage posted and no EBP isolation cart set up outside the door. V14 said she will inform V3 ADON/Infection Coordinator to place a signage and set up for EBP for R129 On 7/22/25 at 2:16PM, V2 DON said residents with indwelling medical devices such hemodialysis catheters for residents on dialysis should be placed on EBP. There should be a clear signage posted on the door or wall outside the resident's room indicating EBP and isolation cart set up available immediately outside the room. On 7/23/25 at 9:24AM, V3 ADON (Assistant DON) said she is the Infection coordinator/preventionist. V3 said residents on dialysis should be placed on EBP. There should be a clear signage posted on the door or wall outside the resident's room indicating EBP and isolation cart set up available immediately outside the room. There should be a written physician order of EBP in resident's chart. V3 said she is responsible for formulating care plan for residents on EBP. Informed V3 of observation made to R129 yesterday, he is on dialysis but no signage of EBP outside his door and no isolation cart set up outside the door. Informed V3 R129 does not have order for EBP and there is no EBP care plan written. V3 said it was an oversight, she placed EBP signage and cart outside R129's door, and she wrote the EBP order in his chart and formulated EBP care plan for R129 yesterday 7/22/25. R129 was admitted on [DATE] with diagnosis listed in part but not limited to Altered mental status, Dependence on renal dialysis, Hypertension, Chronic congestive heart failure. Physician order sheet indicated: AV fistula location on left forearm date 5/19/25. Hemodialysis at Citadel of Glenview with Concerta on these days: MWF. Monitor resident upon return for nausea, vomiting, fatigue, bleeding at site very shift MWF date 5/19/25. On enhance barrier precaution due to left fistula date 7/22/25. Comprehensive care plan indicated: 7/22/25 initiated EBP care plan: R7 requires EBP precautions- noted with left AV fistula. Interventions: Ensure appropriate signage for EBP. Facility's policy on Enhanced Barrier Precaution (EBP) revised March 2023 indicated: Purpose: EBP may be indicated (when contact precaution do not otherwise apply for resident with any of following: *Indwelling medical devices regardless of MDRO colonization status ( central lines, urinary catheters, feeding tubes, hemodialysis catheters, tracheostomies and ventilators).Definitions used in EBP implementation: *Indwelling medical devices include but not limited to central vascular lines ( including hemodialysis catheters), indwelling urinary catheters, feeding tubes and tracheostomy tubes. What are EBP? * EBP expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated.*EBP requires the use of gown and gloves when performing high contact resident care activitiesWhat PPE is required? *Hand hygiene every time*Gown and gloves every time with high contact activities (We are trying to prevent the transfer of multidrug-resistant organism to staff hands and clothing)*PPE required when performing high contact resident care activities. *Post clear signage on the door or wall outside the resident room, indicating the type of precautions and required PPE (gown and gloves)*Make PPE, including gowns and gloves available immediately outside the resident room*Ensure access to alcohol-based hand rub product*Place trash inside the resident room and near the exit for discarding PPE after removal. Facility's signage for Enhanced barrier Precaution from CDC indicated:STOP: Enhanced Barrier Precautions everyone must: Clean their hands, including before entering and when leaving the room.Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, Bathing/showering, Transferring, changing linens, Providing hygiene, Changing briefs or assisting with toileting, Devices care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound care: any skin opening requiring a dressing. *Do not wear the same gown and gloves for the care of more one person. 2. On 7/22/2025 at 9:30 AM during medication pass observation, V14 (Licensed Practical Nurse) performed vital sign on R55 using the facility's durable medical equipment. Reusable blood pressure cuff and pulse oximeter were used to obtain vitals of R55. V14 then stated she was completely done with medication administration for R55 and attempted to proceed to the next resident without cleaning and disinfecting the vital sign medical equipment. V14 stated cleaning and disinfection of reusable vital sign medical equipment must be done after using it. On 7/22/2025 at 10:39 AM, V2 (Director of Nursing) stated vital sign machine must be cleaned and disinfected before and after resident use. Policy and Procedure read: Title: Cleaning and Disinfecting Non-Critical Resident-Care Items, Revised June 2011 Purpose: The purpose of this procedure is to provide guidelines for disinfection of non-critical resident-care items. General Guidelines: 3. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: d. Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment)

Based on observation, interview, and record review the facility failed to implement monitoring of antibiotics. This deficiency affects one (R14) of three residents in the sample of 25 reviewed for Antibiotic Stewardship Program. Findings include: On 7/24/25 at 11:25AM, V3 (Infection Preventionist) said residents should have an infection screening evaluation assessment completed upon the start of antibiotic medication. V3 said R14 should have an assessment completed on 7/14/25. V3 said when she is not in facility the assessments do not get completed on time since she is the only one to do them.On 7/24/25 at 1:55PM, V2 (Director of Nursing) said his expectations for antibiotic stewardship program are for residents to be screened at the start of antibiotics, the infection screening evaluation should be completed in the absence V3.R14 was admitted on [DATE] with diagnosis listed in part but not limited to local infection of the skin and subcutaneous tissue, unspecified. Physician order summary report: Doxycycline 100mg two times a day for 14 days for wound care order date 7/14/25. Infection screening evaluation completed on 7/22/25.Facility Policy for Antibiotic Stewardship- revised 12/2018Policy statement- Antibiotic will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program.1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.Facility Policy for Antibiotic Stewardship- Review and Surveillance of Antibiotics Use and OutcomesPolicy Statement- Antibiotics usage and outcome data will be collected and documented using the facility approved antibiotic surveillance tracking form, The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist or designee.

Based on observation, interview, and record review the facility failed to identify behaviors, failed to notify the psychiatric nurse practitioner of behaviors, and failed to provide appropriate behavioral health services to a resident with multiple mental health diagnoses for 1 of 3 residents (R1) reviewed for behavioral health services. This failure has resulted in R1 refusing to allow facility staff in her room, covering areas of the walls in her room with aluminum foil, towels, sheets, and covering the ceiling vent with plastic wrap. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include major depressive disorder, menopausal and perimenopausal disorder, anxiety disorder, insomnia, paranoid personality disorder, delusional disorders, and unspecified psychosis not due to a substance or known physiological condition. R1's facility assessment dated [DATE] showed no cognitive deficits and R1 to be independent in most cares. The same facility assessment showed R1 to have no behavioral symptoms including hallucinations or delusions. R1's care plan initiated on 3/2/2021 showed, I express maladaptive behavioral symptoms related to: A depressive disorder - attention seeking behavior. The problems and symptoms that I have are manifested by: Reporting/discussing a medication discrepancy that was already resolved in 2020. Prefacing manipulative statements by playing the right card (misinterpreting right issues for personal gain) . I will demonstrate an improvement or reduction in distressing behavioral symptoms in response to behavior management interventions by next review . Explain to me the desired behavior and outcome. Remind me that I am expected to behave respectfully and with maturity. Review rules and behavior expectations with me to help improve my judgement and self-control. R1's care plan last revised 6/16/2021 showed, I may voice false allegations of mistreatment or exploitation by caregivers. This behavior appears to be related to: Feelings of paranoia, fear, powerlessness, helplessness and loss of control. Difficulty controlling anger and depression . R1's care plan last revised 4/29/2021 showed, I display behavioral symptoms related to: Personally feeling displaced and having difficult time adjusting to life in the long term care facility. I manifest these behavioral symptoms through: Socially inappropriate and/or maladaptive disruptive behavior. Manipulative behavior. A disturbed sense of entitlement . Review the behavioral symptoms that I display to determine what strengths or abilities and needs are communicated via the behavior . R1's care plan last revised 10/26/21 showed, I have a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior. My history includes: Conflicts with others. Threatening behavior. Disrespectful, insulting, demeaning behavior . If I become preoccupied by hallucinations, and/or delusional thoughts, do not attempt to talk me out of the delusions. Simply remind me that I am in a safe and secure environment in the facility. Acknowledge to me that it must be difficult for me to be able to function well while having such disturbing thoughts . R1's care plan last revised 12/29/21 showed, I demonstrate behavioral distress related to: Ineffective coping mechanisms. Feeling powerless, out of control. Being challenged by mental illness. The symptoms I have are manifested by: Verbally aggressive behavior when agitated. Use of profanity, demeaning statements, verbal threats and yelling at others . R1's care plan last revised 1/20/23 showed, I display disruptive behavioral symptoms related to persistent mental illness (Paranoid Personality Disorder, Delusional Disorders, Anxiety Disorder, and Major Depressive Disorder). I manifest these behavioral symptoms through visual hallucinations and paranoid/persecutory delusions (i.e.: false belief that I am being stalked, others are deliberately destroying my property, I am a victim of theft or I am being conspired against, there are people outside my window in white sheets, that staff are staring at me and harassing me). Despite reassurances and/or factual information providing otherwise. I have a history of calling authorities via 911 or reporting desire to contact FBI and/or political offices related to my delusions/psychosis (i.e.: to report people in cloaks/sheets in my room, people lighting fireworks outside my bedroom window, seeing footsteps from malevolent people outside . Administer my psychoactive medication as ordered by my physician. Record my behavioral symptoms including verbal/physical aggression, inappropriate behavior and side effects such as tardive dyskinesia and anticholinergic effects . If I become preoccupied by hallucinations, and/or delusional thoughts, do not attempt to talk me out of the delusions. Simply remind me that I am in a safe and secure environment in the facility . Provide me with a psychiatric and psychological evaluation, supportive mental health intervention and treatment recommendations . R1's care plan last revised 1/5/22 showed, I have displayed symptoms of anger related to: Concern, worry regarding medical symptoms and condition. Psychotic symptoms (i.e.: Hallucinations, delusions, especially paranoid delusions. Personality disorder symptoms (i.e.: viewing people/objects as all good or all bad, anger, splitting, confabulation, manipulation, inability to allow myself to be satisfied.) The problem/need that I have is manifested by: Poor listening skills (often becoming angry, defensive, oppositional when assistance and suggestions are provided). Verbal expressions of distress. Persistent insecurity, apprehension, worry . R1's care plan last revised 2/28/22 showed, In spite of repeated counseling attempts, I continue to refuse recommended interventions promoting enhanced mental health and physical well-being. It appears that my resistance and refusals to these interventions are secondary to impaired judgment and insight due to psychiatric illness and rigid personality traits. These symptoms are manifested by refusing to engage in recommended mental health treatment (psychological counseling) . R1's care plan last revised 5/27/2022 showed, DELUSIONAL IDEATIONS: I demonstrate delusional ideations due to persistent mental illness (Paranoid Personality Disorder, Unspecified Psychosis, Delusional Disorders, Anxiety Disorder, and Major Depressive Disorder). I lack adequate reasoning and express bizarre delusional thoughts. The symptoms that I have are manifested by strongly identifying with my past role as an RN and self-diagnosis based on my delusional beliefs. I have used non-prescribed products to treat a rash/itching that I believe was caused from radiation being pumped into my room. I dismiss medically based or prescribed treatments, as I do not trust healthcare professionals and express unfounded belief that I am a victim of malintent. Encourage the resident to share thoughts with a social worker and to engage in listening to the social worker who will help measure/evaluate paranoid thoughts . R1's care plan last revised 1/20/23 showed, DISRUPTIVE BEHAVIOR: I display disruptive behavioral symptoms related to persistent mental illness (Paranoid Personality Disorder, Unspecified Psychosis, Delusional Disorders, Anxiety Disorder, and Major Depressive Disorder). I have a h/o calling authorities via 911 to make false reports rt: delusional beliefs (ie: my food has been tampered with and/or staff are intentionally not distributing my food tray to my liking). I refuse to accept facts that contradict my allegations and hold firm to these fixed beliefs .Provide me with a psychiatric and psychological evaluation, supportive mental health intervention and treatment recommendations . On 12/3/23 at 12:52 PM, this surveyor knocked on R1's door to her room. R1 opened the door a small bit and asked for a moment to finish up a telephone conversation. R1 then reopened the door and allowed this surveyor in her room. R1's sofa was just inside the room on the right hand side. The sofa was covered in sheets. All four walls had areas where aluminum foil was taped to the walls, towels were taped to the walls, tape was placed in areas on each wall, sheets were covering the entire surface of the windows, the television had a towel covering it, the door handle had been taped up completely, and upon entering the room R1 pushed a towel across the gap under the bottom of the door. R1 had shoes in clear plastic bag, a lamp in a clear plastic bag, and there was plastic wrap (like one would use in kitchen) taped on the ceiling covering the vent. R1 had a storage trunk sitting next to her bed covered with plastic and there was a roll of aluminum foil sitting on the trunk. R1 said she has the foil, the towels, and the tape, and the plastic to keep the chemicals from coming into the room and running down the walls. On 12/3/23 at 12:52 PM, R1 pointed to this surveyors face mask and goggles and asked what was going on with wearing these. R1 said, They say they have COVID here now but the testing is being done in this facility not in a lab. They are getting results very fast. I came in with COVID then had it again in the later part of 2022. At that time I was sent to my room by two people who were here working overnight. When I got to my room I felt a blast of chemicals and it all hit me quickly, pain in my arms, and I felt terrible. Then all of a sudden everyone on this hall had COVID. There was something with those two people. There was stuff running down the walls in here. Medications were being tampered with. I had some Prevacid capsules that were small and then longer. I was sick and in pain. I questioned how the Prevacid kept changing. [The facility pharmacy] was handling the medications. I decided I didn't have to get it from them and insurance started sending them to me instead of the facility. I got them. I was taking them all appropriately and I got to have them in my room. Then they came in and said I couldn't have them in the room anymore The stress here is overwhelming. It damages your physical and mental health. They beat the hell out of the guy across the hall. A man from [NAME] went in there. That man went to the hospital and when he came back he wouldn't speak. They got him all mixed up. They can't do this to me because I'm too alert. It is best that I leave here. I've been working with people at [local community program] to get me out of here. I don't like those people. They send different people here every 6-7 months. They were helping me with housing. The DON decreased my lorazepam from 1 mg to 0.5 mg. Its odd because a couple days before that I was having increased depression and anxiety. Then he decreased my Ativan. I was in nursing for 40 plus years, why would you decrease a medication when someone has excessive depression? They need someone to come out here and look at their personnel charts to see who these people are. Administrator doesn't have a license. I know they need a license . I have a PRN (as needed) order for lorazepam I take at night. I know its addicting so I try not to take it but there is a lot of screaming and yelling here at night. I try to avoid but under this stress, anxiety gets high. Someone put another resident up to assaulting me. How can they put psych patients in with other medical patients? . I leave the room to get sheets, towels, and my meals but I come right back because if you leave your room they will come in and do stuff to your room. I think they are afraid to let me go because I know too much . On 12/3/23 at 12:21 PM, V14 (Local Community Programs Social Service Worker/Case Manager) said their program has been working towards getting R1 housing but their team has concerns with her current state of mental health. V14 said V13 RN (Registered Nurse for the Local Community Program) had seen R1 barricaded in her room and laying on the floor with tin foil on her head. V14 said they requested that the facility try and petition R1 for mental health services due to her paranoia, delusions, and the tin foil. The facility said they have not seen these behaviors and have no reason to petition her for mental health services. On 12/4/23 at 11:11 AM, V13 (RN working for the Local Community Program) said, I went into the facility to get a baseline on how [R1] was doing and talk with the staff to see what all she had going on. I was evaluating her to see if she would appropriate to transfer into the community. [V14] had told me about [R1's] behaviors beforehand so we were evaluating to see just how appropriate she would be . When I went in to visit she didn't respond when I knocked on the door, I tried to open the door and the door was barricaded with her couch. The facility said that is very normal for her. I went and got the nurse and I pushed the door open a little bit and we found her in a very deep sleep. She had tin foil wrapped around her head. The facility staff said that was very normal for her. I spoke to a manager type person who I don't remember their name. I asked them if they think she is appropriate to be living in the community by herself. They said yes and that this is her normal behavior. They said it's a response to her being in a nursing home. On 12/3/23 at 3:19 PM, V9 (RN) said she was familiar with R1. V9 said R1 is alert and oriented x 3, but can be forgetful at times. V9 said R1 is very particular and can become very vocal with the staff if they don't respect her wishes. V9 said she's never been in R1's room, but she has seen things over her windows. V9 stated, She doesn't allow us in her room. If we knock, then she will come to the door. Or she will come out here and ask us for something. The surveyor described R1's room and paranoid behaviors and asked V9 if this was concerning. V9 replied, Yes, I would tell the Administrator and DON right away. On 12/3/23 at 3:20 AM, V10 (LPN) replied to the surveyor describing the current status of R1's room with,That's not normal. Those behaviors should be charted in the nurses' notes. I would be concerned and call the doctor. On 12/3/23 at 3:29 AM, V11 (RN) said she is familiar with R1. V11 said R1 is an advocate for herself and very particular on her care. V11 stated, She can over exaggerate. For example, she told me that she heard a man knocking on her window. I never heard anything and there wasn't a man seen outside the building. One time she told me that she hadn't slept much because there was a man outside her window, watching her. The night shift nurse said there was not a man outside her window. No one can confirm her delusions. She doesn't let us in her room. I know she has a lot of stuff. If she comes out of her room and I'm in the hall, then I will glance in. I wasn't able to see much, but she had a lot of stuff in her room . On 12/4/23 at 11:59 AM, V15 RN said he works R1's hall frequently. V15 said he has never been in R1's room or seen R1's room. V15 said R1 will come out and talk to you if she needs something. V15 said R1 has verbalized she thinks chemicals are coming into her room. On 12/3/23 at 2:35 PM V3 DON (Director of Nursing) said, R1 is a very nice person who has a tendency to say things that doesn't exist. She says people are behind the window and knocking on it. She thinks that snipers are on top of the roof . Most of the time she likes to stay in the room and close the door. Since I've been here we haven't sent her out to the hospital or anything like that. I checked with the social worker that was here before me and they said she is always like this. Our psych service comes in every other week to see her. A few times the psych NP has told me that [R1] kicks her out and won't let her in the room. I'm not 100% sure when the last time was she saw her. [R1]was a former nurse before so she thinks she knows everything and doesn't want us to tell her anything. She thinks that she saw a sniper. She thinks chemicals are coming into her room from the outside. She says all kinds of things that we know is not true. She said someone is going to poison her from a chemical outside. Last time I was in the room she had sheets on the walls . It's the delusions that seem to be a problem for her she doesn't think she has delusions. She thinks we have delusions. I think I remember a while ago I went into her room and she was asking me if I can smell a chemical. Psychiatry comes in to see her but she has not been sent out. I would have to check with the psychiatrist to see if she would be a candidate for petition for outpatient psych services. She won't go past the nurses station and then back to her room. I don't think she would go out of this building to anywhere. Even in the summertime I have never seen her go out. Our Social Services should know about her behaviors. Behaviors that would be documented would be aggression. I think she would go back into the community and do well, but she won't let them in. That's her choice and there is nothing we can do about it. I was not aware that she has plastic wrap covering her vent. Maybe I could convince her to let maintenance in the room . If she allowed us to go in to the room it would be different but we can't force into the room. Since there is no aggressive behavior we can't do anything. R1's Behavior Tracking for September 1, 2023 through December 3, 2023 (the date of this survey) there were no behaviors documented for R1. The facility's form for behavior monitoring includes whether or not the resident is having delusions. R1's last Social Services Assessments were completed between 11/10/2022 and 11/13/2022. (Over a year ago.) On 12/3/23 at 2:58 PM, V7 (Facility's Psychiatric Nurse Practitioner) said [R1] was assigned to her at the facility. V7 said she is not sure when the last time she saw [R1] was. V7 said she has not heard anything recently about [R1]. V7 said she was notified that R1 was having increased paranoia, delusions, was refusing treatment, putting tin foil on the walls, taping towels to the walls, and covering the windows. V7 said she certainly did not know that R1 had covered her room vent with plastic wrap. V7 said it is hard for her to know because [R1] doesn't communicate. V7 said she has not seen R1's room. V7 said she would have expected to have been notified of these behaviors and due to the severity of the behaviors she feels that would warrant an involuntary petition. V7 said she would say that R1 needs to be admitted for these behaviors and the petition does not necessarily need to come from her. V7 with R1 covering things like that the facility should have let someone know. The facility's policy revised December 2016 showed, Behavior Assessment, Intervention, and Monitoring, Policy: 1. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. 2. Residents who do not display symptoms of, or have not been diagnosed with, a mental, psychiatric psychosocial adjustment or post-traumatic stress disorder will not develop a pattern of decreased social interaction or increased withdrawn, angry or depressive behaviors that cannot be explained or attributed to a specific clinical condition that makes the pattern unavoidable. Residents will have minimal complications associated with the management of altered or impaired behavior . Assessment: . 3. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: a. Onset, duration, intensity and frequency of behavioral symptoms .

Based on observation, interview, and record review the facility failed to ensure a resident was assessed for self administering medications for 1 of 3 residents (R1) reviewed for medications. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include major depressive disorder, menopausal and perimenopausal disorder, anxiety disorder, insomnia, paranoid personality disorder, delusional disorders, and unspecified psychosis not due to a substance or known physiological condition. On 12/3/23 at 12:53 PM, R1 said, . I questioned how the Prevacid (acid reflux medication) kept changing. [The facility pharmacy] was handling the medications and I decided I didn't have to get them from them so insurance started sending them to me. I get them. I was taking them all appropriately and I got to have them in my room for awhile and then they came in and said I couldn't have them in the room anymore. They just came in today and took them. It was the administrator and the DON (Director of Nursing) that just came in . On 12/4/23 at 11:11 AM, V13 (Registered Nurse for local community program) said, I went into the facility to get a baseline on how [R1] was doing and talk with the staff to see what she had going on. I was evaluating her to see how appropriate she would be to transfer into the community . While I was there the facility staff told me [R1] is the only resident who is allowed to keep her medications in her room. I asked the staff how they know she is taking her medications if she is doing it herself and they said she tells them. Then on the day of our care plan with the facility and [R1] the facility had now all of sudden decided it was inappropriate for her to have her medications in her room. The client said they had just taken her medications on the day we had the care plan. The facility nurse said she gets the medications delivered to her room and she takes them herself. When I knocked on [R1's] door she did not answer, I tried to open the door and the door was barricaded with her couch. The facility said that is very normal for her. I pushed the door open a bit and we found her sleeping. She had tin foil wrapped around her head. The facility staff said that was very normal for her. I question whether or not she should be responsible for her own medications if this is her normal behavior . The facility's assessment titled Self Administration of Medications was completed on 12/3/23 (the day of this survey). There were no other assessments found in R1's record for self administration of medications. On 12/3/23 at 2:35 PM, V3 DON (Director of Nursing) said, She is capable of taking care of her medication, we talked to the doctor this morning and got an order to keep the medications at bedside Initially she was ok with us giving her medications, then she started having this issue. I would have to double check how long she has had her medications in her room. Her medications are delivered to the facility. She won't let us touch them. The facility's policy and procedure titled Self-Administration of Medications showed, Policy: Resident have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Procedure: 1. As part of the overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident 13. The staff and practitioner will periodically (for example, during quarterly MDS reviews) reevaluate a resident's ability to continue to self-administer medications.

Based on observations, interviews and record review, the facility failed to properly clean and sanitize service and dishware. This deficiency has the potential to affect 120 residents receiving food from the kitchen. Findings include: On 09/17/2023 at 9:34 am, during kitchen observation, V4 (Dish Washer) was observed putting dishes in the dishwasher. V3 (Dietary Aide) said V4 does not speak English surveyor asked V3 how the dishwasher temperatures are tested . V3 said a test strip is put in the dishwasher and a cycle is run, and after the washing cycle is complete, the temperature test strip should turn black to indicate the dishwasher washed/sanitized at the right temperature. V4 was asked to test the dishwasher temperatures. V4 put test strip on a plate and ran the dishwasher. Test strip came out white. V4 said the test strip should have turned black to indicate the dishwasher temperatures are on the right temperature. V4 tested the dishwasher 4 times and each time the test strips remained white. On 09/17/2023 at 10:20 am, V5 (Food Service Director) said he would test the dishwasher. V5 put a temperature test strip on a plate and ran the dishwasher. After the wash cycle, the temperature test strip come out white. V5 said the test strip should have turned black to indicate the dishwasher washing temperature is at the correct temperature. V5 said the washing water temperature should be at least 180 degrees F, and the rinse should be at least 160 degrees. V5 said if the washing temperature water does not reach 180/160 degrees, the dishes will not be washed/sanitized properly. V5 said if the dishes are not washed properly, the dishes can get cross contaminated, and bacteria can spread on the dishes and cause food borne illness to the residents. V5 said the temperatures are logged in every day. V5 and surveyor reviewed the Dish Washing Machine temperature log. The last temperature log was completed on 9/14/2023, and the test strip was observed to be white. V5 said the machine should be tested every day to make sure the dishes are washing at the right temperature. On 09/17/2023 at 12:27 pm, V7 (Outside vendor) was observed working on the dishwasher. V7 told V5 that the dish washer washing temperature was at 140 degrees F, and it should be at least 160 degrees F to wash the dishes properly. Dish Washing Machine temperature log documented the last temperature log was documented on 9/14/2023, and the test strip was observed to be white. Facility policy dated May 20, 2023, titled: Machine Washing and Sanitizing (High Temperature Dishwashing Machine) documents: -Dishwashing machines using hot water for sanitizing may be used if the temperature of the wash water is no less than that specified by the manufacturer, which may vary from 150 degrees F to 165 degrees F. -The paper thermometer turns color when it registers 160 degrees F which sanitizes the plate, tableware, utensils etc. (160 degrees F on the dish or utensil surface reflects 180 degrees F at the manifold where the temperature of the dishwashing machine final rinse is measured.

Based on observations, interview and record review, the facility failed to follow their policy on garbage disposal by failing to close lids of the dumpster. This deficiency has the potential to affect all 122 residents residing in the facility. Findings include: On 9/18/2023 at 11:36 am, V5 (Food Service Director) and surveyor went outside to observe the dumpster. The dumpster was observed open on both ends with garbage visible from the outside. V5 said the dumpster covers/lids should be pulled closed after garbage disposal, for infection control, to prevent rodents/rats from getting into the dumpster, and to prevent loose garbage from flying out of the dumpster, which can then spread disease and germs, and spreading germs. On 9/19/2023 at 10:59 am, V17 (Housekeeping/Laundry director) said garbage is collected from the soiled room designated for garbage by the housekeepers, then taken to the dumpster. V17 said the dumpster should be closed so that animals and rain do not get inside the dumpster, as an infection control prevention measure. V17 further stated It is a form of infection control when the dumpsters are closed. the dumpster needs to be covered for infection control. V17 further stated I have never been given a policy on dumpster/garbage refuse policy. I just know in my head that garbage should be covered when being transported, and after it is put in the dumpster, it should be covered for infection control. Facility policy titled Safe Food Handling-Dumpster, dated 2023 documents: -All food will be handled safely and disposed of in a safe manner. The dumpster will be securely covered.

Based on observation, interview, and record review the facility failed to ensure resident personal refrigerator temperatures were maintained at 41 degrees Fahrenheit, failed to clean personal refrigerators regularly to maintain a safe and sanitary environment for food storage, failed to date/label food items, and failed to Discard expired food items after 6 days for 4 residents (R72, R73 R112, R67) reviewed for personal refrigerators in a sample of 25. Findings included: On [DATE] at 10:35 AM, surveyor and V15 [Maintenance Director] made rounds and observed R72, R73, R112, and R67's personal refrigerators. The freezer sections were with thick layer of white ice covering the inside, outside and underneath the freezer sections. No thermometers inside the refrigerators, and personal food containers without dates or labels. The food containers were consisting of meat, salads, and cultural food items. On [DATE] at 11:05 AM, V15 stated, All the residents' personal refrigerators should have a thermometer inside, to make sure the refrigerator is at least 41 degrees Fahrenheit. I do not know why all the personal refrigerators needs a thermometer. I do not know what can happen to a resident if they eat expired food. I check the personal refrigerator temperatures a couple times per week. I do not know what happened to the thermometers that was inside all the personal refrigerators. On [DATE] at 12:47 PM, V17 [Director of Housekeeping] stated, I am responsible for monitoring residents' s personal refrigerator temperatures. I started a few months ago. The logs are from two-to-three months ago. Housekeepers are to clean the inside and wiping down the outside of the refrigerators. The nurse and CNAs are responsible for labeling and dates of food items. Housekeeping staff do not check labels or dates only monitor refrigerator temperatures. On [DATE] at 4:50 PM, V1 [Administrator] stated, All resident refrigerators are monitored everyday by housekeeping and certified nursing assistants [CNA]. All food items should have a date on them with a label if the food came from the kitchen and CNAs places a date on the brought in food. After six days the food is discarded by the housekeeping staff, nursing staff or the manager assigned to that room. Housekeeping staff monitors the temperature daily and keep the outside and inside of the refrigerator clean. If a resident eats food that is older than six days, could potentially make the resident sick. I do not have a year of temperatures, but I assigned the house keeping manager, two weeks ago to monitor all personal refrigerator temps daily and record in the temperature log. Policy documents in part: Foods Brought by Family/Visitors dated (,d+[DATE]) -Food brought into the facility will be labeled - Nursing staff will discard foods before or on the use by date Food Brought in by family or visitors/personal refrigerators -perishable foods are discarded on the sixth day after preparation/opening or the expiration date -personal refrigerators temperatures are maintained at 41 degrees Fahrenheit

Based on interview, and record review the facility failed to follow their resident rights policy by failing to allow one resident (R90's) durable power of attorney for health care, to enter the facility to visit R90. 1 resident (R90) out of 3 reviewed for resident rights in the sample of 25. Findings Include, R90's clinical record documents in part; R90 is a [AGE] year-old with medical diagnosis of dementia, osteoarthritis, essential hypertension, chronic kidney disease, dysphagia, anxiety and adult failure to thrive. Minimum data set [MDS] Brief Interview Mental Status score [5] dated (10/11/22) indicates R90 is severely cognitively impaired. On 9/19/23 at 3:30 PM, V34 [R90's Durable Power of Attorney of Health Care] per phone interview stated, I drive from down state Illinois and stay in a hotel for a week. During that time, I stay with R90 from 8am to 8PM. I feed, bathe, clothe, wash hair, and apply lotion to R90. I encourage her to drink fluids and provide social interaction due to R90 only speaks Korean and has dementia. I have to speak up for R90, because she is not able to communicate with most of the staff. On 9/12/23, the administrator called the police and kicked me out of the facility. It all started because the dietary cook and I discussed R90's food, and the cook did not care for suggestions. On 9/12/23, V1 [Administrator] and V6 [Assistant Administrator] came to me in the hallway, wanted to discuss my concerns with the cook. V1 was accusing me of being rude to the cook, which was not true. V1 did not ask me what happened, V1 automatically accused me. I began to talk to V1 when V6 started yelling and told me not to talk while V1 was speaking. Then V6 and I began to have words because V6 had nothing to do with the situation. V1 then walked away from me while I was speaking, I returned back into R90's room. Around fifteen minutes later, V1 and a police officer came and asked me to leave the facility, because I was disturbing the peace. I left the facility. On 9/16/23, my family member went to visit R90 and observed a bruise on the side above R90's left ear. My family member asked V26 [Registered Nurse] what happened, the nurse said she did not know what happened and R90 was seen by the nurse practitioner and R90 was okay. V26 also suggested that the bruise could have come from a perm that R90 had in the middle of August, that did not make any sense at all. Next V26, said R90 always likes laying on her left side, resting her head on the side rail could have cause the bruise. I thought maybe that could be possible. On 9/18/23, I live about three hours away from the facility, I came there around 12 noon to visit with R90 and to make sure she was doing well. I was walking to the facility door, when V1 came outside and asked me if I saw my email this morning. I told V1 no I have not checked my emails. V1 told me to go back to my car and check my email because my visitations were modified, and I was not allowed to enter the facility. I went back to my car and the email from V1 read: Dear V34, I hope this letter finds you well. To ensure the safety and comfort of all our visitors and residents, we have established the following visitation guidelines: Please make an appointment for your visit 24 hours in advance by contacting V1. This helps us ensure your loved one is ready for your visit when you arrive. Some areas within our facility are limited to you. Please follow any guidance from our staff regarding where you can and cannot go. You may have access to the coffee station and sitting areas in front of the reception desk. We kindly request that all visitors behave respectfully and courteously towards our residents, staff, and other visitors. Disruptive behavior will not be tolerated. Your visit will be limited to one hour to ensure our residents and staff maintain their routine. Please cooperate with any time restrictions that may apply. We appreciate your cooperation in following these visitation guidelines. They are in place to create a safe and pleasant environment for everyone. If you have any questions or need further information, please do not hesitate to contact me. I could not believe it; I called the police for assistance. Once the police arrived, V1 came outside. I explained the whole situation to the police officer and asked for a wellbeing check on R90. V2 [Director of Nursing] brought R90 outside for me to see her. I observed a bruise on the left side of her head above the ear. I told the police, V1, and V2 I was taking R90 to the hospital for an evaluation. At that time, I noted a sign on the door that indicated IDPH was conducting a annual survey and anyone could speak to them. V1 told me that the surveyors would not speak to me and to call the hotline number, so that is what I did. I knew V1 was not telling the truth, because he never went into the building to ask the surveyor if I could speak to them, so I knew that was not true. V1 did not want me to tell everything to the state surveyor. R90 had a CT scan of the head, and it was negative, but R90 has a urinary tract infection. On 9/19/23 at 5:20 PM, V1 stated, I restricted V34's visitation guidelines on 9/12/23. V34 was asked to leave the facility due to her having an outburst. V6 and I went to speak with V34 about her behavior and speaking to staff disrespectfully, and her disruptive behavior was not allowed. During the conversation V34 began to yell, while we were standing in the hallway at V6 and I. V34 kept cutting me off while I was speaking, and V6 asked her to allow me to speak. V34 began to speak to V6 disrespectful so V6 and I walked away from V34. I went to my office and V34 went back into R90's room. I decided to restrict V34's access to the facility due to V34's outburst. I called the police for them to witness and notify V34 to leave the facility. At that time, I told V34 in the presence of the police, she will receive new visitation guidelines. V34 did not make any verbal or physical threats to me, staff or any residents. V34 was disruptive in the hallway. I did meet with V34 in the hallway to have a conversation. The conversation did not occur in my office or private area. On 9/18/23, I sent V34 her new visitation guidelines. The guidelines included, that V34 would have to notify me 24-hours in advance notice to visit, some areas of the facility were restricted, V34 could visit with R90 at the reception area near the coffee machine for one hour. On 9/18/23, I saw V34 about to enter the facility and I met her in front of the facility. I asked V34 if she checked her email to review her visitation guidelines. V34 walked away. A little while later V34 came back to the facility with the police to conduct a well being check. V34 told me that she wanted to take R90 to the emergency room for an evaluation. I explained the staff will get R90 ready and she will have to wait a few minutes. While waiting for R90, V34 asked to speak to the surveyors, I explained that she [V34] was not allowed in the building and could call the hotline phone number. Meanwhile, V2 called R90's physician, gave report to the hospital, and printed off paperwork for the emergency room and then brought R90 outside to V34. Later, I was notified that R90 was admitted to the hospital for urinary tract infection. All head scans were negative for injury in relation to the discoloration noted on R90's left side of head. Reviewed V1 email that was sent to V34 dated 9/18/23 at 8:28 AM. Indicates V34 need to call 24 hours in advance for a visit, visitation will occur in the reception area near coffee machine, the visit will be for one hour. Policy: Documents in part: Resident Rights -Federal and state laws guarantee certain basic rights to all residents of this facility -resident's has the right to visit and be visited by others from outside the facility

Based on observation, interview and record review the facility failed to ensure proper grooming for one resident (R322) in a sample of 25 residents reviewed for activities of daily living care. Findings include: On 9/17/23 at 11:50 AM, Observed R322 sitting in a wheelchair in R322s room. Observed R322 fingernails to be long and dirty. R322 stated I want my fingernails cut. My husband (V31) asked last week. He went to the desk to ask someone. I don't know who he talked to. On 9/17/23 at 2:44 PM, V31 (R322 family member) stated, last week Wednesday I asked a nurse to cut R322's fingernails. R322 is diabetic and if R322 scratches self it could be a bad thing. I don't think they (staff) clean the fingernails. They (staff) brought a pair of clippers in here today and left them, but they did not cut the nails. I don't know if they brought them in here for me to cut R322 nails. On 9/17/23 at 2:50 PM, V32 (Licensed Practical Nurse) stated R322's fingernails are long. If residents' fingernails are too long, they can scratch and injure themselves. To prevent infection, you have to keep fingernails short if the resident lets you. CNAs (Certified Nursing Assistants) can cut fingernails but not toenails. On 9/19/23 at 1:50 PM, V2 (Director of Nursing) stated for ADL (activities of daily living) care, V2 expects staff to change residents when residents are wet to shower residents when scheduled twice a week to provide incontinent care. V2 expects staff to keep residents clean and dry, to do oral care, to comb hair, to make sure the resident is neat, clean, and dry. Staff can cut fingernails. Nurses and CNAs (Certified Nursing Assistants) can provide fingernail care, can cut fingernails. If family asks and we determine that the nails are long enough, then they should be cut by staff. If staff see that nails are dirty or too long then they should clean and cut the nails. They should be cut within the same day that the resident asks. If staff is busy, they can ask someone else to do it. If not able to do it the same day, then it should be done the next day. We cut and clean nails so nails are clean and nice. According to R322 MDS assessment, August 28, 2023, R322 requires extensive assistance for personal hygiene with one-person physical assist. Facility policy Activities of Daily Living (ADLs), Supporting, March 2018, documents in part: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident an in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care)

Based on observation, interview and record review the facility failed to ensure proper use of pressure relieving devices. This failure affected one resident (R322) out of 3 reviewed for air mattress pressure in a sample of 25 residents reviewed. Findings include: On 9/17/23 at 2:45 PM, Observed R322 lying in bed with a low-air-loss mattress. The control panel for the low air loss mattress was set to 230lbs and observed multiple fabric layers between R322 and the mattress. On 9/17/23 at 3:00 PM, V32 (Licensed Practical Nurse) stated I never touch the device (low-air-loss mattress control panel). V32 said the control panel should be set to the resident's weight and there should only be one layer between the resident and the mattress. V32 confirmed on R322's mattress there was a flat sheet, a pad, a second flat sheet folded 2 times (4 layers), R322 was wearing an adult brief and the control panel was set to 230lbs. On 9/17/23 at 3:25 PM, V2 (Director of Nursing) confirmed that R322 was on a low-air-loss mattress with a pump. The pump is set to 230lbs. V2 said the pump is set to the weight of the resident and there should be one layer between the resident and the mattress. V2 confirmed R322 mattress had a flat sheet, a pad, a draw/pull sheet (flat sheet folded two times) on it and R322 was wearing an adult brief. V2 said for a low-air-loss mattress, it's supposed to have a flat sheet only. There should not be that many layers between the resident and the mattress. With too many layers, the resident is not getting the benefit of the mattress. The mattress is to provide pressure relief to prevent pressure ulcers. On 9/19/23 at 11:08 AM, V30 (Wound Care Coordinator) stated Monday through Friday when I do the wound treatments, I check the weight of the patient versus the settings on the low-air-loss mattress machine. The setting on the machine should reflect what the resident's weight is. The nurses and CNAs (Certified Nursing Assistants) know about it. Sometimes during care, they (nurses, CNAs) accidentally hit the knob and it changes the setting. If it is not set correctly the resident is not receiving the full benefit of the mattress. The resident is on the mattress for pressure ulcer prevention and to promote healing. Only cover the low air loss mattress with a flat sheet. Only the flat sheet should be between the resident and the mattress. The flat sheet should not be folded. There should not be a pad or pull sheet on the mattress. If the flat sheet is folded twice that is 4 layers. The pad is hard. For residents with pressure ulcers, we don't use the pull sheet or the pad. The resident will not get the full benefits of the mattress. There should only be the adult brief and the flat sheet between the resident and the low air loss mattress. The setting should be set to the patient's weight. I put the weight of the resident on the machine weekly, that is what the resident weighted that week. Weights and Vitals Summary, 9/19/23, documents in part: R322 weight on 9/14/2023 is 172lbs, on 9/8/2023 is 183lbs, on 9/1/2023 is 175lbs. R322 Patient Risk Profile, printout date 9/18/23, documents in part: Braden Score, risk for acquiring pressure wounds, is 8 (Very High Risk). Preventive Interventions-Recommendations include use pressure redistribution surface if bed or chair bound. Wound Assessment Details Report, printout date 9/18/23, documents in part: Sacrum (V30 stated report is mislabeled with sacrum, should be coccyx and the 2 names are sometimes used interchangeably), present on admission, date identified 8/22/23, R322 readmitted to the facility from the hospital 8/22/23. Seen at bedside for skin assessment and noted coccyx unstageable pressure ulcer wound present. Resident on turning and repositioning, air mattress. Braden score 8 (very high risk). R322 care plan documents in part: R322 has pressure ulcer r/t Immobility with dx: fall at home and PMH: hypomagnesemia, diabetes, and hypertension. Facility policy Support Surface Guidelines, September 2013, documents in part: Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface such as foam gel, static air, alternating air, or air-loss or gel when lying in bed. Follow manufacturers direction for low-air-loss mattresses. Proactive Medical Products operation manual documents in part: Protekt Aire 3000 pump and mattress system is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. Operating Instructions: Patients can directly lie on the mattress or cover with a sheet and tuck loosely to increase the comfort of the patient. Determine the patient's weight and set the control knob to that weight setting on the control unit. Facility policy Pressure Ulcers/Skin Breakdown - Clinical Protocol, April 2018, documents in part: The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings and application of topical agents. Facility provided Inservice Form, 9/17/23, topic: Inservice on air loss mattress use.

Based on observation, interview, and record review, the facility failed to follow their smoking safety policy, Failed to ensure that smoking materials are not kept by resident at bedside. Failed to ensure that resident was evaluated upon admission for safety of smoking. Failure to ensure that resident was re-evaluated for their ability to smoke safely on readmission, quarterly or annual basis. These failures affected 1 resident (R69) of 5 residents reviewed for smoking in the sample of 25. Findings include: On 09/17/23 at 10:57 AM, R69 stated he keeps his cigars and lighters with him. R69 opened drawer next to the chair R69 was sitting in, reached into drawer, and showed surveyor 1/2 pack labeled Red 2.0 Premium Filtered Cigars and three disposable lighters. On 09/17/23 at 11:19 AM, V2 (Director of Nursing) observed R69's smoking equipment stored in R69's drawer including the three lighters. V2 stated, we didn't know he had those with him and he shouldn't have them in his room and he's on oxygen which is a safety concern. On 09/17/23 at 11:29 AM, surveyor viewed R69's electronic health record (EHR) and did not see a Smoking Assessment or Safe Smoking Evaluation or a Smoking Care plan. On 09/17/23 at 4:05 PM, V9 (Director of Social Services) stated if a resident smokes, then a Smoking Assessment is completed upon admission, readmission, quarterly, annually and any resident who smokes should also have a smoking care plan. V9 stated that there is never a situation wherein a resident is allowed to keep their smoking supplies in their room because this is for that resident and the rest of the resident's safety. V9 stated if a resident who has the lighter is on oxygen, they could blow up the whole building. V9 stated R69 should not have his smoking equipment including no lighters in his room and that the nurse should be holding R69's smoking equipment. Surveyor asked V9 about R69's Safe Smoking Assessment signed on 09/17/23 and V9 stated V9 opened it on 03/06/23 and stated there are no quarterly re-assessments from 06/2023 or 09/2023 when quarterly MDS assessments were completed. V9 stated, I can look into it and I don't remember what I did. V9 stated that R69's smoking care plan was added today. On 09/19/23 at 12:39 PM, V9 (Social Service Director) stated R69 is allowed to smoke with supervision, R69 does not have independent smoking privileges. R69 was initially admitted to the facility on [DATE]. R69's diagnosis included but not limited to Chronic Obstructive Pulmonary Disease (COPD), Chronic Diastolic (Congestive) Heart Failure, Nicotine Dependence, Obstructive Adult Sleep Apnea, Dependence on Supplemental Oxygen. R69's Order Summary Report dated 09/17/23 documents in part 3.5-liter oxygen with nasal cannula continuous with start date 09/27/22. R69's Care Plans as of 09/17/23, 11:29AM which did not have a smoking care plan. R69's Smoking Safety Screen signed on 09/17/23 by V9 documents in part facility needs to store resident's lighter and cigarettes and that R69 needs supervision to smoke. R69's MDS (Minimum Data Set) dated 06/02/23 indicates intact cognition with BIMS (Brief Interview for Mental Status) 15/15, supervision required with bed mobility, transfer, walking, locomotion, dressing, toilet use and personal hygiene. Facility policy titled, Smoking Policy-Residents dated 07/2017 documents in part the facility shall establish and maintain safe resident smoking practices, the resident will be evaluated on admission and the resident's ability to smoke safely will be re-evaluated quarterly, and a resident without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc. Facility Assessment documents in part residents who may pose a hazard to themselves and others with smoking materials may have their cigarettes, lighters and matches removed from them and kept in a designated location for safety.

Based on observation, interview and record review the facility failed to follow a physician order for fluid restrictions. This failure affected 2 residents (R12, R43) out of 5 reviewed for nutrition care in a sample of 25. Findings include: On 09/17/23 at 12:03 PM, observed water pitcher in R43's room on top of R43's chest of drawers. R43 denies being on a fluid restriction. On 09/17/23 at 12:58 PM, observed R43's meal ticket at lunch. R43's meal ticket did not document that R43 is on a fluid restriction or restrict fluids in any way. R43 received 6-8 ounces hot tea on lunch tray from disposable cup. On 09/17/23 at 12:10 PM, observed the following items on R12's bedside table next to R12's bed: empty water pitcher, one disposable cup 50% filled with apple juice, one disposable cup 75% filled with coffee, small plastic cup 25% filled with water, and empty small plastic cup. Observed sign on R12's wall above R12's bed that documented R12 is on a 1.2-liter Fluid Restriction. On 09/17/23 at 12:48 PM, observed R12 receive lunch tray. R12's meal ticket did not document that R12 is on a fluid restriction or restrict fluids in any way. 6 ounces hot tea added to tray by Certified Nursing Assistant (CNA). Observed R12 drinking soup brought in by R12's wife. On 09/17/23 at 12:12 PM, V19 (Licensed Practical Nurse) observed empty water pitcher and cups on R12's bedside table. V19 stated R12 is on a fluid restriction because of being on dialysis to prevent fluid overload and that R12 should not have a water pitcher or extra fluids in his room at bedside. V19 stated, I will remove them now. V19 stated R12 is on 1.2-liter fluid restriction and the allotment of fluid is divided up between nursing and dietary. V19 stated the water pitcher is not calculated into the fluid restriction which is why R12 should not have it in his room. On 09/18/23 at 12:53 PM, V5 (Food Service Director) stated if a resident is on a fluid restriction it would be specified on the meal ticket and include the amount of fluid allowed at every meal so that the kitchen staff would know what foods need to be calculated as part of the fluid restriction and the Certified Nursing Assistants on the unit would know how many ounces of fluid they can give a resident for beverages at each meal. V5 stated that having the fluid restriction information on the meal ticket is the way the kitchen communicates the physician diet order to the staff upstairs serving the resident their tray. V5 stated the meal ticket would be the first point of contact to alert the nursing staff about the fluid restriction, but they could also check the Electronic Health Record (EHR) or ask the nurse for this information. On 09/18/23 at 1:13 PM, V5 viewed R12 and R43's menu profile and printed R12 and R34's meal tickets from the kitchen computer to provide to the surveyor. V5 stated R12 and R43 are not on fluid restrictions but are on therapeutic diets. V5 stated R43 is limited to 4 oz, milk per day related to therapeutic diet restrictions, not because of a fluid restriction. On 09/18/23 at 1:43 PM, V10 (Registered Dietitian) stated if a resident is on a fluid restriction, then it should be on ticket. V10 stated that unless information about a fluid restriction is listed on the meal ticket the kitchen staff placing food on the trays and the CNAs serving the beverages wouldn't know to restrict fluids and the allowance would not be met accurately. V10 stated that residents on fluid restriction should not have water pitchers in their room and that all fluids, from water to juice to coffee to ice cream to gelatin to soup must be calculated as part of the fluid restriction. V10 stated R43 is on a 1-liter fluid restriction (500 milliliters (ml) nursing, 500 ml dietary) and R12 is on a 1.2-liter fluid restriction (600 ml nursing, 600 ml dietary) to prevent the accumulation of fluid in their body because they are on dialysis. On 09/18/23 at 12:35 PM, V11 (Dialysis Registered Nurse) stated it is important for dialysis residents on fluid restrictions to follow them because removing too much fluid can cause low blood pressure, muscle cramping, and could cause a resident to pass out. V11 stated if a resident does not follow the fluid restriction, then they may need to add another treatment or extend their treatment time. V11 stated R43 is on a fluid restriction and that sometimes R43 drinks too much, and his blood pressure runs low which is why it is important for him to follow his fluid restriction. V11 stated a few months ago R43's dialysis run time had to be extend three hours to 3.25 hours to remove more fluid without causing R43's blood pressure to drop. On 09/19/23 at 12:14 PM, observed water pitcher on R43's chest of drawers in R43's room. V20 (Certified Nursing Assistant) stated R43 is not on a specific fluid restriction but V20 tries not to give R43 too much because R43 is on dialysis. On 09/19/23 at 12:29 PM, V5 stated that as of this morning all the residents with orders for fluid restriction have their fluid restriction listed on their meal tickets. V5 stated it was not done before today because the kitchen was not notified about those residents who had physician orders for fluid restrictions. Upon request V5 printed new copy of R12 and R43's meal tickets dated 09/19/23. R12's diagnosis included but not limited to End Stage Renal Disease, Dependence on Renal Dialysis, Heart Failure, Hypotension, Dementia. R12's Order Summary Report dated 09/17/23 documents in part 1.2 liter per day fluid restriction 200 cc AM shift, 200 cc PM shift, 200 cc Night shift. Total for nursing 600 cc. R12's Nursing Care Plan dated 01/23/23 documents in part R12 has order for 1.2 liter per day dx: Congestive Heart Failure, End Stage Renal Disease and 600 cc total for nursing. R12's Nutrition Care Plan dated 01/15/23 documents in part R12 is on a fluid restriction 1200 milliliters per day, encourage resident to comply with fluid restriction and no water pitcher on bedside. R12's MDS (Minimum Data Set) dated 08/07/23 indicates moderately impaired cognition with BIMS (Brief Interview for Mental Status) 12/15, supervision required with eating, extensive assistance required with bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. R12 on dialysis. R12's Nutrition/Dietary Note dated 09/12/23, 17:30 documents in part 1.2-liter fluid restriction per day (nursing 600 cc, dietary 600 cc). R43's diagnosis included but not limited to End Stage Renal Disease, Dependence on Renal Dialysis, Chronic Diastolic (Congestive) Heart Failure. R43's Order Summary Report dated 09/19/23 documents in part fluid restriction total 1000 milliliter (ml) per 24 hours. Nursing 500 ml, Dietary 500 ml. Notify dietary of meal liquid amounts order date 05/12/23. R43's Nutrition Care Plan dated 11/22/22 documents in part R43 is on a 1000 ml fluid restriction, encourage resident to follow fluid restriction and no water pitcher on bedside. R43's MDS (Minimum Data Set) dated 08/08/23 indicates intact cognition with BIMS (Brief Interview for Mental Status) 14/15, limited assistance required with bed mobility, transfer, locomotion, eating, toilet use, and personal hygiene. R43 on dialysis. R43's Nutrition/Dietary Note dated 09/17/23, 23:45 documents in part fluid restriction: 1000 milliliters (mls) per 24 hours. Nursing 500 mls/day. Dietary 500 mls/day. R12 and R43's Lunch Meal Tickets dated 09/18/23 do not indicate R12 and R43 are on fluid restrictions. R12 and R43's Lunch meal Tickets dated 09/19/23 indicate R12 and R43 are on fluid restrictions as part of their diet order after being adjusted by V5. Facility policy titled, Physician Orders dated 02/2019 documents in part all orders including medications, treatments, labs, and ancillary orders must be ordered by a licensed physician and that all orders will be processed and carried out by nursing service personnel as soon as the order has been received. Kitchen policy titled, Fluid Restriction dated 2017 documents in part fluids are restricted as ordered in the medical record, fluids are anything that is liquid at room temperature or melts at room temperature such as water, tea, coffee, milk, soft drinks, juice, popsicles, ice cream, sherbet, gelatin, and soup, and the tray care specifies the fluids provided by the food & nutrition services. Kitchen policy titled, Distribution of Fluid Restrictions dated 2017 document in part when a strict total volume restriction is ordered, the allotted volume will need to be divided between nursing and food & nutrition services.

Based on observation, interview and record review the facility failed to date and change oxygen equipment every 7 days per facility policy and ensure oxygen cannula tubing is placed in a bag when not in use. These failures apply to 1 resident (R69) out of 5 reviewed for oxygen therapy in a sample of 25. Findings include: On 09/17/23 at 10:55 AM, observed R69 sitting in chair at bedside with oxygen concentrator behind him and oxygen tubing attached to the concentrator with oxygen cannula tubing laying on the floor near R69's feet and garbage can. Oxygen concentrator was not in use. On 09/17/23 at 11:06 AM, R69 stated that he uses oxygen everyday and that the oxygen tubing is not changed on a regular basis and was never given any type of container or storage bag to put the nasal cannula tubing in when not in use. R69 stated he drapes the oxygen tubing on top of the oxygen concentrator when oxygen is not in use. R69 stated the oxygen tubing falls on the floor sometimes and that no one does anything about it. On 09/17/23 at 11:09 AM, observed piece of tape wrapped around the oxygen tubing dated 08/07/23. On 09/17/23 at 11:10 AM, V20 (Certified Nursing Assistant) came into R69's room and looked at the oxygen tubing and stated that the date on the tubing was labeled 08/07/23. On 09/17/23 at 11:13 AM, V2 (Director of Nursing) stated that oxygen tubing is changed weekly on Sunday and as needed. V2 stated when the oxygen cannula tubing is not in use it should be stored in a clean plastic bag. V2 observed R69's oxygen cannula tubing on the floor. V2 stated the oxygen tubing should not be on the floor because the floor is unclean and potentially could make a resident sick. On 09/17/23 at 11:16 AM, V2 observed oxygen cannula tubing and V2 read out loud the date labeled on the tubing as 08/07/23. V2 stated the oxygen tubing should have been changed before today. R69's diagnosis included but not limited to Chronic Obstructive Pulmonary Disease (COPD), Chronic Diastolic (Congestive) Heart Failure, Nicotine Dependence, Obstructive Adult Sleep Apnea, Dependence on Supplemental Oxygen. R69's Order Summary Report dated 09/17/23 documents in part 3.5-liter oxygen with nasal cannula continuous with start date 09/27/22. R69's Care Plan dated 02/06/23 documents in part R69 has oxygen therapy related to Congestive Heart Failure (CHF), Obstructive Sleep Apnea (OSA) and COPD. R69's MDS (Minimum Data Set) dated 06/02/23 indicates intact cognition with BIMS (Brief Interview for Mental Status) 15/15, supervision required with bed mobility, transfer, walking, locomotion, dressing, toilet use and personal hygiene. Facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection dated 11/2011 documents in part, the purpose of this procedure is to guide prevention of infection associated with respiratory therapy, tasks, and equipment. Steps in the procedure included but not limited to change the oxygen cannula and tubing every seven days or as needed, keep the oxygen cannulae and tubing in a plastic bag when not in use.

Based on interview and record review, the facility neglected to provide care and services to adequately care for and manage the treatment of a resident admitted to the facility with a lower extremity immobilizer by not appropriately monitoring the condition of the resident's skin under the immobilizer for over two weeks. This failure applied to one (R3) resident reviewed for pressure ulcers and resulted in R3 developing an unstageable, deep tissue pressure injury, which was facility acquired. Findings include: R3 is an [AGE] year-old female admitted to the facility on [DATE] post hospitalization related to a right ankle fracture. R3 has a history of hypertension, pre-diabetes, gastritis, and hypokalemia. R3 does not speak English fluently and can communicate minimally in English; native language spoken is Hindi. Admission MDS (Minimum Data Set) assessment dated [DATE] documents 0 total number of venous and arterial ulcers present; Bed Mobility and Transfer requires extensive assistance with support of two+ persons physical assist and is incontinent of bowel and bladder. Resident most current plan of care includes intervention for risk of skin breakdown that includes to monitor and check skin on a daily basis. New Patient Admission Report includes, under Notes and Follow-Ups: Boots all time, off - shower, weight bearing on left foot. Discharge documentation from hospital includes that R3 should wear CAM Boot AAT (at all times), WBAT (weight-bearing as tolerated), Ice, Elevate, and Acute pain management. Admission summary note dated 6/3/23 12:51, documents that R3 skin is intact upon head-to-toe assessment, with right ankle healed blister and right outer ankle healing abrasion. Physician Order Summary report includes the following physician orders: - Skin checks daily every shift. Order Date: 6/3/2023 - Order for leg booth (sic) to be worn on all shifts every shift for pressure sore. Order Date: 6/16/23 - Ortho: -CAM Boot AAT -WBS:WBAT -Ice -elevate - acute pain management. Order Date: 6/3/23 - Boot on only for ambulation, off in bed and when sitting, daily skin and wound check, WBAT. Order Date: 6/21/23 - Boot on only for ambulation, off in bed and when sitting, daily skin and wound check, WBAT. every shift. Order Date: 6/22/23 - Heel offloading at all times while in bed every shift for pressure wound. Order Date: 6/19/23 TAR (Treatment Administration Record) documents that orders for daily skin checks were carried out daily, every shift, as ordered from 6/3/23 - 6/23/23. New Admission Skin assessment dated [DATE] for R3 has a skin integrity score of 0 with no documented skin issues/concerns. Facility provided Skin Condition Reports dated 6/6 (shower and skin check is marked off), 6/9 (no areas checked off), 6/13 (no areas checked off), 6/16 (no areas checked off), and 6/20 (change in color - red, bluish, pale, gray, etc. checked off). 9/15/23 at 2:34 PM V9 (LPN) was asked about regular facility protocols regarding skin assessments on residents. V9 said for new admissions, there is a full skin assessment conducted by two staff members, hospital discharge orders are reviewed and entered. If they are already being seen by a wound doctor or have orders, those will be entered in the system. If the resident has a boot, they will unstrap the boot and check the skin and put the boot back on. The boot should be taken off and skin assessed every shift, and it should be documented in the daily skin check assessment. Any changes should be reported to the wound care team. 9/15/23 at 2:52 PM V22 (CNA) said that she never noticed R3 without the boot on (her leg). V22 said she would provide care for R3 and would give her bed baths and that the boot was not removed during baths. V22 said she never noticed any skin issues on R3 and would have reported it if she did. Nursing Progress Note written by V10 (Wound Coordinator) dated 6/5/23 12:30 reads: Note Text: Resident is a 85 y/o female admitted from local Hospital with Dx: DISPLACED COMMINUTED FRACTURE OF SHAFT OF RIGHT FIBULA, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING with PMH of Epilepsy, BPPV, hx of mild hyponatremia, GERD, prediabetes, osteoarthritis, glaucoma, hypertension. Alert and oriented Indian speaking. Seen at bedside for skin assessment and noted cam boot to right lower foot and lar purplish discoloration to left lower quadrant. Otherwise, skin is intact. [sic] Nursing Progress Note written by V18 (RN) dated 6/17/23 00:00 reads: applied left foot leg boot for left heel discoloration looks like purple color. also reposition to sides. [sic] Per nutrition/dietary note written on 6/19/23 13:57, (R3) has DTPI (deep tissue pressure injury) to L heel and intervention recommended was 1) MVI 1T qd., 2) liquid protein 30ml BID, 3) Juven 1pkt BID. These will aid in wound healing. Monitor and follow-up. [sic] Progress Note written by V19 (Nurse Practitioner) 6/23/23 12:04 reads: HPI: Nursing brought my attention for right LE pressure ulcer/discoloration. Notes chronic right LE pain with movement; participates OT/PT. Her appetite fair. Denies nausea vomiting constipation diarrhea. Reviewed arterial us BLE result and discussed the medical plan with her son and nursing team; moderate to severe arteriosclerotic disease. Denies acute pain in her right foot at rest at this time. Will consult (physician named) wound specialist for recommendation; communicated with nursing team and wound team. Will start doxycycline 100mg one dose now and bid x 10 days for now for empirical abx tx. Pt was seen by orthopedic surgeon on 6/21/2023. Nursing noted pressure 100s this morning before amlodipine 5mg ; will hold amlodipine for now; will readjust next week . ASSESSMENT/PLAN: -Right LE pressure ulcer/PAD: acute, likely 2/2 pressure from boot and underlying PAD; arterial u/s noted moderate to severe arteriosclerotic disease . Nurse progress noted dated 6/23/23 16:31 reads: BLE doppler results reviewed by (physician named) with the following new order - Received N.O. from (physician) to send resident to local hospital ER for eval and tx. Order noted and carried out. Called ambulance company with ETA of 1.5 hours. Son notified of order to send resident to ER for evaluation. Facility provided Pressure Ulcer UN-Avoidability Form dated 6/22/23, which documents: - Site: Right heel, Type: Pressure, Length: 3.5 cm, Width: 5.0 cm - Date Noted: 6/19/2023 - Site: Left heel, Type: Pressure, Length: 3.1 cm, Width: 1.2 cm - Date Noted: 6/21/2023 - Site: Right ankle to R foot, Type: Pressure, Length: 19.0 cm, Width: 6.0 cm - Date Noted: 6/21/2023 - Site: Right medial malleolus (ankle), Type: Pressure, Length: 2.5 cm, Width: 3.0 cm - Education interventions are listed as: offload heel at all times while in bed - Family or Resident Response to Education provided as: Family comes everyday and given instructions to make sure both heels are offloaded from pressure 9/16/23 at 2:27 PM V17 (R3's son/POA) said that the facility never discussed or had any education to him or family regarding importance of taking off CAM boot to assess skin. On the contrary, V17 said that he asked if they should be taking the boot off periodically and was told no. Per V17, nurses kept saying it was up to PT to decide. When he asked PT, they would say it was up to the nurse practitioner. V17 said that he knew they were wrong when they came back from the ortho doctor appointment, and the Director of Nursing apologized numerous times. V17 said, (V3 Director of Nursing) said to me that he would have expected the nurses to be removing the boot to examine the skin and said that he would personally be holding the person responsible, accountable for this. I don't remember the names of any of the staff other than V3. I know there were multiple nurses and from PT there was a lady and a young gentleman .I asked the nurse practitioner (V19) if I should take her to the hospital after we saw the wound at the ortho appointment and she said no, the hospital isn't going to do anything that we can't do here. Then the next day they called and told me they were sending her out to the hospital. At the hospital, they said it was caused by the CAM boot pressure .she was admitted for a week. I believe they did debride it and on top of it the blood flow issues she developed required a stent to improve the blood flow. She almost lost her leg. She had an ACE wrap, then the boot, so the orthopedic doctor said her leg was just cooking under all of that pressure from the wrap and then the boot. When she discharged from the hospital V3 called and asked if we would give them another chance, but I refused and instead took her to another skilled facility for wound care primarily because the fracture was already mostly healed. I just brought her home about two weeks ago, it's healing but it's still red and gets puss, they might have to do more debridement. They come to the house to do her wound care and the doctor is coming to see it this week, but she can barely walk, and it looks really bad still. 9/16/23 at 5:20 PM V18 (RN) said, I usually work overnight. No, they told us not to remove it (regarding R3's boot). I don't remember ever taking it off, I never took it off. I just check if the leg is swollen and if she had any pain or discomfort. We do not remove it to check the skin at nighttime. I'm not sure about during the day shift. She never complained about pain at nighttime. I never noted any issues with her skin at all. One time I saw the son and we talked about her sleep, accu-chek, vital signs, discomfort, etc. Whenever I asked her if there was anything I could do for her she would just shake her head no. 9/15/23 at 3:41 PM V10 (Wound Coordinator) stated, daily skin assessments are done on basically everybody, especially the high-risk patients. Braden score over 10, I think, regardless of risk, there is a daily skin check. During care, like showers, change of briefs, and ADL's the skin is checked. If the resident has a CAM boot, there is a daily skin check. For R3, the order from the hospital was to wear the CAM boot at all times and the son had ordered us not to touch it and he was here every day. When she first came in, I did a thorough skin assessment and took it (boot) off but then put it back. During daily skin checks, the nurses don't take the boot off to check the skin. Because of the orders and the son, we didn't get a chance to look at it. She complained of so much pain, she would not let us touch it either. One day I noticed some discoloration and then that's the time that I took it off to check. She had a light compression wrap and then the boot; the wrap didn't get changed. I think the son thought it would get checked when she goes to her follow up with the surgeon. On the 19th (6/19/23), I noticed the left heel, which didn't have a boot or anything. I asked the son if I could check the right side and he said no, don't touch the CAM boot per doctor. Son was always in the room. I got orders from the NP for the left heel, which was a DTI and she told me to document conversation with the son. Arterial doppler was done and result came back on the 23rd and we sent her out because of the occlusion. When I took off the CAM boot, I saw DTIs (deep tissue pressure injury). If the son would have allowed us it could have been prevented. 9/15/23 at 4:27 PM, V3 (Director of Nursing) said, regarding new patients, we do skin checks from head to toe and note any skin concerns and if they have wounds. We try to do it as soon as we can, it should be done by the admitting nurse for the patient. Usually, the wound team will also do a follow up assessment. For residents who have a removable cast, etc. it depends on the order, we can't remove it. If the order is not specifically saying, do not remove, then we can take it off, inspect the skin and put it back. If it's not removable then we inspect the part that we can see, that is exposed. That would all be documented under assessment .(R3) we did the doppler and it showed that there was arterial circulation issues and per the doppler the right was worse than the left. For example, the boot or the splint, we should be able to put our two fingers under it, if not, then that means that it's too tight. If there's an imprint it could be that it's too tight or it could be that there is more pressure on the leg depending on if they are laying, etc. I would expect for the nurses to sign off that they did the daily or every shift for checking the skin around the boot. If they have the order and it says to ice it depends, maybe as needed or for pain measures. The order said to wear it at all times so they should not remove it. This was unavoidable because the son said we are not supposed to touch it. 9/15/23 at 5:33 PM V20 (Nurse Practitioner) said that a reasonable expectation would be to inspect the skin and put it (boot) back on. I typically just go in on the weekend. I hadn't seen this patient recently and I vaguely remember. Any removable device, it's reasonable to take it off for a couple minutes to assess the integrity of the skin. Surveyor confirmed with V20 that the order for boot was under his name in physician orders and V20 said, if that order was put in under me, I rarely go against what the hospital orders upon discharge. I would assume that's common sense that you should take it often from time to time to assess the skin. 9/15/23 at 5:46 PM V19 (Nurse Practitioner) said, I think I saw a discoloration (regarding R3). I think she came back from orthopedic, and they found discoloration or an ulcer or something. Either me or the wound doctor ordered ultrasound. It's a flow issue. Wounds can develop due to ulcer or blood flow issue. She had PVD. I do expect the staff to inspect the skin under the CAM boot .I believe but not sure 100% if I talked to them (son and daughter) about the skin. Doctor ordered boot to be worn all the time. She complained about pain a lot. Surveyor asked if V19 ever assessed the skin or the area herself, given R3's medical history and complaints of pain. V19 responded, I tried to remove it, but she was in so much pain, so I just went off the documentation from the wound nurse. Surveyor then asked V19 if she would expect nursing to remove any removable devices to assess the skin underneath and V19 responded, Absolutely, yes, as long as the patient allows. The patient has the right to refuse but then we have to educate them. Staff should assess regularly. 9/16/23 at 3:10 PM V21 (Physical Therapist) said, I work at the facility as needed. I think I only did R3's initial evaluation. I think she was complaining about pain, and she was wearing a boot. I am trying to remember. R3 was max assist with bed mobility. I think I only did the assessment. The boot is to be worn at all times, even when she is in bed .I don't know if there is a policy. I always give education to the nurse and the CNA about what to do and what not to do. I told them to make sure they check the skin when they give a sponge bath or anything; to check for redness or skin tears. She was a little confused at times and was only speaking Hindi - she can understand English but could only speak one or two words. She would speak Hindi to me. I'm sure I told them that whenever they have a boot or neck brace or something like that, to take it off and check for any redness or areas like bony prominences and then put it back on. I just had a patient yesterday actually with a neck brace and I told them the same thing. At least they should be taking it off to check the skin once a day and then putting it back on. I'm pretty positive about the nurse outcomes and they always follow what we tell them. 09/16/2023 at 10:17 AM, V1 (Administrator) provided pain assessments for R3 for 6/3/23 and 6/21/23, with no other pain assessments provided other than what is documented on R3's MAR (medication administration record). Surveyor review of MAR does not show that resident was experiencing increase in pain level per documentation. V1 affirmed that per V3 (Director of Nursing), daily skin check orders should encompass all areas; we do not have a specific order for the CAM boot area. The order for cam boot instructions from the hospital was provided to surveyor for review. Surveyor also reviewed shower sheets for resident skin and advised V1 that there is no documentation on the shower sheets indicating condition of R3's skin or indication that the skin under the boot was being monitored. V1 expressed understanding of this concern expressed by surveyor. Hospital record reviewed for R3's admission on 6/23/23, after transfer from facility. Chief complaint is vascular problem and foot swelling. Admitting diagnoses include: peripheral artery disease, dry gangrene, arterial thromboembolism, leg swelling, leg pain, and acute deep vein thrombosis of right lower extremity. Emergency department note dated 06/23/23 19:47 documents that R3 presented to emergency room (ER) with right foot wound and note continues to read that there was no significant interval evaluation of fracture site or skin condition .patient with increased right lower extremity swelling and discoloration of skin multiple sites . Assessed with vascular surgery, to ED for evaluation, imaging consistent with chronic occlusive peripheral arterial disease, aspirin only at this time. Admit to hospitalist service for further clinical monitoring and management of peripheral arterial disease complicated by pressure ulcers and soft tissue injury of right foot/ankle secondary to splint .Physical Exam notes include: EXTREMITIES: R foot with purple discoloration, edematous. Decreased sensation to bottom of R foot. Dry gangrene noted to distal R shin. Unable to palpate pedal pulse . ASSESSMENT/PLAN: (R3) . who presents today with abnormal arterial doppler. Since right distal fibula fracture 5/22, patient has had CAM boot on, went for follow up on 6/21 who noticed wound and discoloration to RLE. Patient is afebrile. Not tachycardic or hypotensive. Not tachypneic or hypoxic. Consulted (MD) covering for vascular, recommending CTA, continue aspirin, admission with vascular medicine to follow . TRIAGE NOTE: Pt to ED c/o right ankle/foot swelling, redness, and vascular problem Pt had ankle fx (did not need surgery) about a month ago, dressed with walking boot and was admitted here. Pt was transferred to Citadel for rehab. During this entire time including admission here pt's son saying that they did not take the patient out of the walking boot the entire time to check about 4 weeks. ACE wrap was underneath the boot. Was only taken out once for an I&D for a small cyst on the tibia, which is healed Pt's foot with dark pressure injury/pressure ulcer appearing as CAM boot outline + heel pressure ulcer - appears unstageable Doppler study today at Citadel showing poor flow Pt awake, alert, Hindi speaking with pt's son translating . Hospital medical record includes photo of R3's lower right extremity, are on top of foot and above ankle are dark purple, almost black in color. Visible imprint on skin covering large area of top of foot and front part of lower extremity. Facility provided Pressure Ulcers/Injuries Overview dated July 2017, which includes: Purpose The purpose of this procedure is to provide information regarding clinical identification of pressure ulcers/injuries and associated risk factors, which is derived from the definitions in S483.25(b)(1) Pressure ulcers (F686). Staging pressure ulcers/injuries for purposes the MDS assessments will reference current definitions in the Resident Assessment Instrument User's Manual. Definitions Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. Avoidable/Unavoidable Avoidable means that the resident developed a pressure ulcer/injury and that the one or more of the following was not completed: Evaluation of the resident's clinical condition and risk factors; Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; Monitoring or evaluation of the impact of the interventions; or Revision of the interventions as appropriate. Unavoidable means that the resident developed a pressure ulcer/injury even though the following were completed: Evaluation of the resident's clinical condition and risk factors; Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; Monitoring or evaluation of the impact of the interventions; and Revision of the interventions as appropriate . Eschar/Slough Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color; and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound . Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration DTPI is intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle and/or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Medical Device Related Pressure Ulcer/Injury: Medical device related PU/PIs result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system . Facility provided Prevention of Pressure Ulcers/Injuries dated July 2017 which reads: Purpose The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment 1. Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. 2. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity - any evidence of existing or developing pressure ulcers or injuries; b. Tissue tolerance - the ability of the skin (and supporting structures) to endure the effects of pressure; and c. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Use a screening tool to determine if resident is at risk for under-nutrition or malnutrition. 4. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., nonblanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); c. Wash the skin after any episodes of incontinence, using pH balanced skin cleanser; d. Moisturize dry skin daily; and e. Reposition resident as indicated on the care plan . Monitoring 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis.

Based on interview and record review, the facility failed to prevent skin breakdown by not regularly and thoroughly assessing and monitoring the condition of a resident's skin, who was at risk for skin breakdown and wearing an immobilizer on lower extremity. This failure applied to one (R3) resident reviewed for pressure ulcers and resulted in R3 developing unstageable, deep tissue pressure injuries to lower extremity, which were facility acquired. Findings include: R3 is an [AGE] year-old female admitted to the facility on [DATE] post hospitalization related to a right ankle fracture. R3 has a history of hypertension, pre-diabetes, gastritis, and hypokalemia. R3 does not speak English fluently and can communicate minimally in English; native language spoken is Hindi. Admission MDS (Minimum Data Set) assessment dated [DATE] documents 0 total number of venous and arterial ulcers present; Bed Mobility and Transfer requires extensive assistance with support of two+ persons physical assist and is incontinent of bowel and bladder. R3's most current plan of care includes intervention for risk of skin breakdown that includes to monitor and check skin on a daily basis. New Patient Admission Report includes, under Notes and Follow-Ups: Boots all time, off - shower, weight bearing on left foot. Discharge documentation from hospital includes that R3 should wear CAM Boot AAT (at all times), WBAT (weight-bearing as tolerated), Ice, Elevate, and Acute pain management. Admission summary note dated 6/3/23 12:51, documents that R3's skin is intact upon head-to-toe assessment, with right ankle healed blister and right outer ankle healing abrasion. Physician Order Summary report includes the following physician orders: - Skin checks daily every shift. Order Date: 6/3/2023 - Order for leg booth (sic) to be worn on all shifts every shift for pressure sore. Order Date: 6/16/23 - Ortho: -CAM Boot AAT -WBS:WBAT -Ice -elevate - acute pain management. Order Date: 6/3/23 - Boot on only for ambulation, off in bed and when sitting, daily skin and wound check, WBAT. Order Date: 6/21/23 - Boot on only for ambulation, off in bed and when sitting, daily skin and wound check, WBAT. every shift. Order Date: 6/22/23 - Heel offloading at all times while in bed every shift for pressure wound. Order Date: 6/19/23 MAR (Medication Administration Record) reviewed and shows that resident pain was monitored every shift as ordered upon admission thru 6/23/23 with most pain scores being documented as zero. Pain Assessment Effective Date: 6/3/23 with score 4. Pain Assessment Effective Date: 6/21/23 with score 4. New Admission Skin assessment dated [DATE] for R3 has a skin integrity score of 0 with no documented skin issues/concerns. Facility provided Skin Condition Reports dated 6/6 (shower and skin check is marked off), 6/9 (no areas checked off), 6/13 (no areas checked off), 6/16 (no areas checked off), and 6/20 (change in color - red, bluish, pale, gray, etc. checked off). 9/15/23 at 2:34 PM V9 (LPN) was asked about regular facility protocols regarding skin assessments on residents. V9 said for new admissions, there is a full skin assessment conducted by two staff members, hospital discharge orders are reviewed and entered. If they are already being seen by a wound doctor or have orders, those will be entered in the system. If the resident has a boot, they will unstrap the boot and check the skin and put the boot back on. The boot should be taken off and skin assessed every shift, and it should be documented in the daily skin check assessment. Any changes should be reported to the wound care team. 9/15/23 at 2:52 PM V22 (CNA) said that she never noticed R3 without the boot on (her leg). V22 said she would provide care for R3 and would give her bed baths and that the boot was not removed during baths. V22 said she never noticed any skin issues on R3 and would have reported it if she did. Nursing Progress Note written by V10 (Wound Coordinator) dated 6/5/23 12:30 reads: Note Text: Resident is a 85 y/o female admitted from local Hospital with Dx: DISPLACED COMMINUTED FRACTURE OF SHAFT OF RIGHT FIBULA, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING with PMH of Epilepsy, BPPV, hx of mild hyponatremia, GERD, prediabetes, osteoarthritis, glaucoma, hypertension. Alert and oriented Indian speaking. Seen at bedside for skin assessment and noted cam boot to right lower foot and lar purplish discoloration to left lower quadrant. Otherwise, skin is intact. [sic] Nursing Progress Note written by V18 (RN) dated 6/17/23 00:00 reads: applied left foot leg boot for left heel discoloration looks like purple color. also reposition to sides. [sic] Wound Medical Record Assessment Details Reports provided include: - Wound: left heel, Type: Pressure, Source: Facility-acquired, Date Identified: 6/19/23, Assessment Date: 6/19/23 10:16 AM, Clinical Stage: Deep Tissue Pressure Injury, Tissue Types: Deep Maroon = 100%, Size (cm): 3.10x1.20xUnknown (LxWxD), Current Plan & Comments reads: 6/22/2023 12:51 PM by V10 (Wound Nurse): Resident is a 85 YO female with PMH: Comminuted fracture of shaft of right fibula, subsequent encounter of closed fracture with routine healing, GERD, Difficulty in walking, not elsewhere classified and hyperglycemia. Seen at bedside for skin assessment and noted DTI (deep tissue pressure injury) to left heel. Treatment applied as ordered and tolerated well with no complains of pain or discomfort. Son, NP, and RD notified. On heel offloading at all times while in bed. Son is present during assessment and the writer ask to check the other foot and son replied no, there's no problem on that foot. Resident on cam boot to right LLE. Braden score of 10 (high risk). Will continue to assess. - Wound: right ankle to right dorsal foot, Type: Pressure, Source: Facility-acquired, Date Identified: 6/21/23, Assessment Date: 6/22/23 10:10 AM, Clinical Stage: Deep Tissue Pressure Injury, Tissue Types: Deep Maroon = 100%, Size (cm): 19.00x6.00xUnknown (LxWxD), Current Plan & Comments reads: 6/22/2023 12:51 PM by V10 (Wound Nurse): Resident is a 85 YO female with PMH: Comminuted fracture of shaft of right fibula, subsequent encounter of closed fracture with routine healing, GERD, Difficulty in walking, not elsewhere classified and hyperglycemia. Seen at bedside for skin assessment and noted DTI to right anterior ankle to right dorsal foot due to cam boot. Resident wears cam boot due to right fibula fracture. Per ortho visit resident now will wear cam boot for PT/ambulation only. Treatment applied as ordered and tolerated well with no complains of pain or discomfort. Son present on assessment, NP and RD notified. On heel offloading at all times while in bed. Braden score of 10 (high risk). Will continue to assess. - Wound: right medial malleolus, Type: Pressure, Source: Facility-acquired, Date Identified: 6/21/23, Assessment Date: 6/22/23 10:14 AM, Clinical Stage: Deep Tissue Pressure Injury, Tissue Types: Deep Maroon = 100%, Size (cm): 2.50x3.00xUnknown (LxWxD), Current Plan & Comments reads: 6/22/2023 12:48 PM by V10 (Wound Nurse): Resident is a 85 YO female with PMH: Comminuted fracture of shaft of right fibula, subsequent encounter of closed fracture with routine healing, GERD, Difficulty in walking, not elsewhere classified and hyperglycemia. Seen at bedside for skin assessment and noted DTI to right medial malleolus due to cam boot. Resident wears cam boot due to right fibula fracture. Per ortho visit resident now will wear cam boot for PT/ambulation only. Treatment applied as ordered and tolerated well with no complains of pain or discomfort. Son present on assessment, NP and RD notified. On heel offloading at all times while in bed. Braden score of 10 (high risk). Will continue to assess. - Wound: right heel, Type: Pressure, Source: Facility-acquired, Date Identified: 6/21/23, Assessment Date: 6/22/23 10:16 AM, Clinical Stage: Deep Tissue Pressure Injury, Tissue Types: Deep Maroon = 100%, Size (cm): 3.50x5.00xUnknown (LxWxD), Current Plan & Comments reads: 6/22/2023 12:49 PM by V10 (Wound Nurse): Resident is a 85 YO female with PMH: Comminuted fracture of shaft of right fibula, subsequent encounter of closed fracture with routine healing, GERD, Difficulty in walking, not elsewhere classified and hyperglycemia. Seen at bedside for skin assessment and noted DTI to right heel due to cam boot. Resident wears cam boot due to right fibula fracture. Per ortho visit resident now will wear cam boot for PT/ambulation only. Treatment applied as ordered and tolerated well with no complains of pain or discomfort. Son present on assessment, NP and RD notified. On heel offloading at all times while in bed. Braden score of 10 (high risk). Will continue to assess. Per nutrition/dietary note written on 6/19/23 13:57, (R3) has DTPI (deep tissue pressure injury) to L heel and intervention recommended was 1) MVI 1T qd., 2) liquid protein 30ml BID, 3) Juven 1pkt BID. These will aid in wound healing. Monitor and follow-up. [sic] Progress Note written by V19 (Nurse Practitioner) 6/23/23 12:04 reads: HPI: Nursing brought my attention for right LE pressure ulcer/discoloration. Notes chronic right LE pain with movement; participates OT/PT. Her appetite fair. Denies nausea vomiting constipation diarrhea. Reviewed arterial us BLE result and discussed the medical plan with her son and nursing team; moderate to severe arteriosclerotic disease. Denies acute pain in her right foot at rest at this time. Will consult (physician named) wound specialist for recommendation; communicated with nursing team and wound team. Will start doxycycline 100mg one dose now and bid x 10 days for now for empirical abx tx. Pt was seen by orthopedic surgeon on 6/21/2023. Nursing noted pressure 100s this morning before amlodipine 5mg ; will hold amlodipine for now; will readjust next week . ASSESSMENT/PLAN: -Right LE pressure ulcer/PAD: acute, likely 2/2 pressure from boot and underlying PAD; arterial u/s noted moderate to severe arteriosclerotic disease . Nurse progress noted dated 6/23/23 16:31 reads: BLE doppler results reviewed by (physician named) with the following new order - Received N.O. from (physician) to send resident to local hospital ER for eval and tx. Order noted and carried out. Called ambulance company with ETA of 1.5 hours. Son notified of order to send resident to ER for evaluation. Nurse progress note dated 6/23/23 22:19 reads: Called local hospital and spoke with (hospital staff name) resident admitted with arterial disease. All departments notified. Facility provided Pressure Ulcer UN-Avoidability Form dated 6/22/23, which documents: - Site: Right heel, Type: Pressure, Length: 3.5 cm, Width: 5.0 cm - Date Noted: 6/19/2023 - Site: Left heel, Type: Pressure, Length: 3.1 cm, Width: 1.2 cm - Date Noted: 6/21/2023 - Site: Right ankle to R foot, Type: Pressure, Length: 19.0 cm, Width: 6.0 cm - Date Noted: 6/21/2023 - Site: Right medial malleolus (ankle), Type: Pressure, Length: 2.5 cm, Width: 3.0 cm - Education interventions are listed as: offload heel at all times while in bed - Family or Resident Response to Education provided as: Family comes everyday and given instructions to make sure both heels are offloaded from pressure 9/16/23 at 2:27 PM V17 (R3's son/POA) said that the facility never discussed or had any education to him or family regarding importance of taking off CAM boot to assess skin. On the contrary, V17 said that he asked if they should be taking the boot off periodically and was told no. Per V17, nurses kept saying it was up to PT to decide. When he asked PT, they would say it was up to the nurse practitioner. V17 said that he knew they were wrong when they came back from the ortho doctor appointment, and the Director of Nursing apologized numerous times. V17 said, (V3 Director of Nursing) said to me that he would have expected the nurses to be removing the boot to examine the skin and said that he would personally be holding the person responsible, accountable for this. I don't remember the names of any of the staff other than V3. I know there were multiple nurses and from PT there was a lady and a young gentleman .I asked the nurse practitioner (V19) if I should take her to the hospital after we saw the wound at the ortho appointment and she said no, the hospital isn't going to do anything that we can't do here. Then the next day they called and told me they were sending her out to the hospital. At the hospital, they said it was caused by the CAM boot pressure .she was admitted for a week. I believe they did debride it and on top of it the blood flow issues she developed required a stent to improve the blood flow. She almost lost her leg. She had an ACE wrap, then the boot, so the orthopedic doctor said her leg was just cooking under all of that pressure from the wrap and then the boot. When she discharged from the hospital V3 called and asked if we would give them another chance, but I refused and instead took her to another skilled facility for wound care primarily because the fracture was already mostly healed. I just brought her home about two weeks ago, it's healing but it's still red and gets puss, they might have to do more debridement. They come to the house to do her wound care and the doctor is coming to see it this week, but she can barely walk, and it looks really bad still. 9/16/23 at 5:20 PM V18 (RN) said, I usually work overnight. They told us not to remove it (regarding R3's boot). I don't remember ever taking it off, I never took it off. I just check if the leg is swollen and if she had any pain or discomfort. We do not remove it to check the skin at nighttime. I'm not sure about during the day shift. She never complained about pain at nighttime. I never noted any issues with her skin at all. One time I saw the son and we talked about her sleep, accu-chek, vital signs, discomfort, etc. Whenever I asked her if there was anything I could do for her she would just shake her head no. 9/15/23 at 3:41 PM V10 (Wound Coordinator) stated, daily skin assessments are done on basically everybody, especially the high-risk patients. Braden score over 10, I think, regardless of risk, there is a daily skin check. During care, like showers, change of briefs, and ADL's the skin is checked. If the resident has a CAM boot, there is a daily skin check. For R3, the order from the hospital was to wear the CAM boot at all times and the son had ordered us not to touch it and he was here every day. When she first came in, I did a thorough skin assessment and took it (boot) off but then put it back. During daily skin checks, the nurses don't take the boot off to check the skin. Because of the orders and the son, we didn't get a chance to look at it. She complained of so much pain, she would not let us touch it either. One day I noticed some discoloration and then that's the time that I took it off to check. She had a light compression wrap and then the boot; the wrap didn't get changed. I think the son thought it would get checked when she goes to her follow up with the surgeon. On the 19th (6/19/23), I noticed the left heel, which didn't have a boot or anything. I asked the son if I could check the right side and he said no, don't touch the CAM boot per doctor. Son was always in the room. I got orders from the NP for the left heel, which was a DTI and she told me to document conversation with the son. Arterial doppler was done and result came back on the 23rd and we sent her out because of the occlusion. When I took off the CAM boot, I saw DTIs (deep tissue pressure injury). If the son would have allowed us it could have been prevented. 9/15/23 at 4:27 PM, V3 (Director of Nursing) said, regarding new patients, we do skin checks from head to toe and note any skin concerns and if they have wounds. We try to do it as soon as we can, it should be done by the admitting nurse for the patient. Usually, the wound team will also do a follow up assessment. For residents who have a removable cast, etc. it depends on the order, we can't remove it. If the order is not specifically saying, do not remove, then we can take it off, inspect the skin and put it back. If it's not removable then we inspect the part that we can see, that is exposed. That would all be documented under assessment .(R3) we did the doppler and it showed that there was arterial circulation issues and per the doppler the right was worse than the left. For example, the boot or the splint, we should be able to put our two fingers under it, if not, then that means that it's too tight. If there's an imprint it could be that it's too tight or it could be that there is more pressure on the leg depending on if they are laying, etc. I would expect for the nurses to sign off that they did the daily or every shift for checking the skin around the boot. If they have the order and it says to ice it depends, maybe as needed or for pain measures. The order said to wear it at all times so they should not remove it. This was unavoidable because the son said we are not supposed to touch it. 9/15/23 at 5:33 PM V20 (Nurse Practitioner) said that a reasonable expectation would be to inspect the skin and put it (boot) back on. I typically just go in on the weekend. I hadn't seen this patient recently and I vaguely remember. Any removable device, it's reasonable to take it off for a couple minutes to assess the integrity of the skin. Surveyor confirmed with V20 that the order for boot was under his name in physician orders and V20 said, if that order was put in under me, I rarely go against what the hospital orders upon discharge. I would assume that's common sense that you should take it often from time to time to assess the skin. 9/15/23 at 5:46 PM V19 (Nurse Practitioner) said, I think I saw a discoloration (regarding R3). I think she came back from orthopedic, and they found discoloration or an ulcer or something. Either me or the wound doctor ordered ultrasound. It's a flow issue. Wounds can develop due to ulcer or blood flow issue. She had PVD. I do expect the staff to inspect the skin under the CAM boot .I believe but not sure 100% if I talked to them (son and daughter) about the skin. Doctor ordered boot to be worn all the time. She complained about pain a lot. Surveyor asked if V19 ever assessed the skin or the area herself, given R3's medical history and complaints of pain. V19 responded, I tried to remove it, but she was in so much pain, so I just went off the documentation from the wound nurse. Surveyor then asked V19 if she would expect nursing to remove any removable devices to assess the skin underneath and V19 responded, Absolutely, yes, as long as the patient allows. The patient has the right to refuse but then we have to educate them. Staff should assess regularly. 9/16/23 at 3:10 PM V21 (Physical Therapist) said, I work at the facility as needed. I think I only did R3's initial evaluation. I think she was complaining about pain, and she was wearing a boot. I am trying to remember. R3 was max assist with bed mobility. I think I only did the assessment. The boot is to be worn at all times, even when she is in bed .I don't know if there is a policy. I always give education to the nurse and the CNA about what to do and what not to do. I told them to make sure they check the skin when they give a sponge bath or anything; to check for redness or skin tears. She was a little confused at times and was only speaking Hindi - she can understand English but could only speak one or two words. She would speak Hindi to me. I'm sure I told them that whenever they have a boot or neck brace or something like that, to take it off and check for any redness or areas like bony prominences and then put it back on. I just had a patient yesterday actually with a neck brace and I told them the same thing. At least they should be taking it off to check the skin once a day and then putting it back on. I'm pretty positive about the nurse outcomes and they always follow what we tell them. 09/16/2023 at 10:17 AM, V1 (Administrator) provided pain assessments for R3 for 6/3/23 and 6/21/23, with no other pain assessments provided other than what is documented on R3's MAR (medication administration record). Surveyor review of MAR does not show that resident was experiencing increase in pain level per documentation. V1 affirmed that per V3 (Director of Nursing), daily skin check orders should encompass all areas; we do not have a specific order for the CAM boot area. The order for cam boot instructions from the hospital was provided to surveyor for review. Surveyor also reviewed shower sheets for resident skin and advised V1 that there is no documentation on the shower sheets indicating condition of R3's skin or indication that the skin under the boot was being monitored. V1 expressed understanding of this concern expressed by surveyor. Hospital record reviewed for R3's admission on 6/23/23, after transfer from facility. Chief complaint is vascular problem and foot swelling. Admitting diagnoses include: peripheral artery disease, dry gangrene, arterial thromboembolism, leg swelling, leg pain, and acute deep vein thrombosis of right lower extremity. Emergency department note dated 06/23/23 19:47 documents that R3 presented to emergency room (ER) with right foot wound and note continues to read that there was no significant interval evaluation of fracture site or skin condition .patient with increased right lower extremity swelling and discoloration of skin multiple sites . Assessed with vascular surgery, to ED for evaluation, imaging consistent with chronic occlusive peripheral arterial disease, aspirin only at this time. Admit to hospitalist service for further clinical monitoring and management of peripheral arterial disease complicated by pressure ulcers and soft tissue injury of right foot/ankle secondary to splint .Physical Exam notes include: EXTREMITIES: R foot with purple discoloration, edematous. Decreased sensation to bottom of R foot. Dry gangrene noted to distal R shin. Unable to palpate pedal pulse . ASSESSMENT/PLAN: (R3) . who presents today with abnormal arterial doppler. Since right distal fibula fracture 5/22, patient has had CAM boot on, went for follow up on 6/21 who noticed wound and discoloration to RLE. Patient is afebrile. Not tachycardic or hypotensive. Not tachypneic or hypoxic. Consulted (MD) covering for vascular, recommending CTA, continue aspirin, admission with vascular medicine to follow . TRIAGE NOTE: Pt to ED c/o right ankle/foot swelling, redness, and vascular problem Pt had ankle fx (did not need surgery) about a month ago, dressed with walking boot and was admitted here. Pt was transferred to Citadel for rehab. During this entire time including admission here pt's son saying that they did not take the patient out of the walking boot the entire time to check about 4 weeks. ACE wrap was underneath the boot. Was only taken out once for an I&D for a small cyst on the tibia, which is healed Pt's foot with dark pressure injury/pressure ulcer appearing as CAM boot outline + heel pressure ulcer - appears unstageable Doppler study today at Citadel showing poor flow Pt awake, alert, Hindi speaking with pt's son translating . Hospital medical record includes photo of R3's lower right extremity, are on top of foot and above ankle are dark purple, almost black in color. Visible imprint on skin covering large area of top of foot and front part of lower extremity. Facility provided Pressure Ulcers/Injuries Overview dated July 2017, which includes: Purpose The purpose of this procedure is to provide information regarding clinical identification of pressure ulcers/injuries and associated risk factors, which is derived from the definitions in S483.25(b)(1) Pressure ulcers (F686). Staging pressure ulcers/injuries for purposes the MDS assessments will reference current definitions in the Resident Assessment Instrument User's Manual. Definitions Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. Avoidable/Unavoidable Avoidable means that the resident developed a pressure ulcer/injury and that the one or more of the following was not completed: Evaluation of the resident's clinical condition and risk factors; Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; Monitoring or evaluation of the impact of the interventions; or Revision of the interventions as appropriate. Unavoidable means that the resident developed a pressure ulcer/injury even though the following were completed: Evaluation of the resident's clinical condition and risk factors; Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; Monitoring or evaluation of the impact of the interventions; and Revision of the interventions as appropriate . Eschar/Slough Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color; and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound . Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration DTPI is intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle and/or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Medical Device Related Pressure Ulcer/Injury: Medical device related PU/PIs result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system . Facility provided Prevention of Pressure Ulcers/Injuries dated July 2017 which reads: Purpose The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment 1. Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. 2. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity - any evidence of existing or developing pressure ulcers or injuries; b. Tissue tolerance - the ability of the skin (and supporting structures) to endure the effects of pressure; and c. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Use a screening tool to determine if resident is at risk for under-nutrition or malnutrition. 4. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., nonblanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); c. Wash the skin after any episodes of incontinence, using pH balanced skin cleanser; d. Moisturize dry skin daily; and e. Reposition resident as indicated on the care plan . Monitoring 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis.

Based on observation, interview and record review, the facility failed to develop and/or follow any fall prevention policy and procedures; failed to implement fall-risk care plan interventions to ensure the resident's immediate environment was free of accident hazards; failed to adequately supervise and monitor residents; and failed to ensure assistive/alerting devices were in place to prevent accidental falls with injuries for 4 (R1, R2, R3, R4) of 4 residents reviewed for accident/hazards in the sample of 7 residents. Theses failures resulted in R1 sustaining multiple fractures to the face, ribs, and shoulder, R2 sustaining a hip fracture with surgical intervention, R3 with massive bleeding due to head trauma with required suturing, and R4 with head trauma, bleeding, and sutures. All 4 residents required emergent transfers to the hospital for medical treatment. Findings include: 1. R1 is a [AGE] year-old having diagnoses listed in part with dementia, gait abnormality, lack of coordination, fracture of humerus, laceration of part of head, maxillary fracture, and fracture of body of mandible. On 4/21/23 at 10:15 AM, V1 (Administrator) and V2 (DON/Director of Nursing) presented surveyor with R1's facility-reported incident of 1/30/23 and with all requested reportable and non-reportable incidents, along with incidents the facility was currently investigating. Interview with V2 stated, R1 was observed falling from her wheelchair while in the dining room during dinner. The nurse heard R1's alarm go off but (V12) was unable to get to her in time. R1 fell to the ground, and she had a cut to her chin and was sent out to the hospital and came back with sutures but no other injuries. Review of R1's progress notes contradicts V2's statement that R1 required only suturing when sent to the hospital. Facility progress notes written by V12 (LPN/Licensed Practical Nurse) dated 1/30/2023 22:15 showed, Incident Note: Received a call from on-call guardian, stated that resident is admitted for observation due to lung bruising and rib fractures. DON (V2-Director of Nursing) notified. V12 (LPN) wrote a subsequent entry in the progress note dated 2/2/2023 at 4:47 PM Admission Summary: readmitted this [AGE] year-old female with diagnosis of maxillary fracture, fracture of mandibular condyle, laceration of lips and chin, right side Pulmonary Embolism, Lower Left Extremity Deep Vein Thrombosis. Transferred resident to bed by ambulance crew. Resident is awake and verbally responsive. Confused and disoriented. Able to somehow respond appropriately to closed ended questions. Denies pain at this time. Notified MD/ NP, orders verified, noted, and carried out. On-call guardian notified of readmission, also consents obtained for psycho-therapeutic medications. Hospital records dated 1/30/23 reads in part, Date of admission: 1/30/2023. Chief complaint: Fall. History of Present Illness: (R1) is a [AGE] year-old female with primary history significant for general weakness, dementia, depression, epilepsy, right humerus fracture, presents due to witnessed fall at nursing home. Got up from bed and fell on to face. Reports mild pain around mouth. Very poor historian. Does not recall events. In the ER: found to have a pulmonary embolism, Multiple facial fractures. Assessment and plan: Suspected mechanical fall out of bed and sustained facial trauma-- fractures of maxilla and mandible, including into teeth. ER consulted plastics and maxillofacial surgeon. Started on antibiotics for head/neck coverage regarding lip laceration and facial fractures. V1 (Administrator) and V2 (Director of Nursing) were interviewed again regarding the inaccuracies of V2's report showing R1's report of injury, V1 and V2 stated, We're sorry, we just realized that the report was wrong and we will correct the report today to be submitted to your office. Surveyor asked if there were other omissions or inaccuracies not presented to surveyor, V1 and V2 stated, No we reported everything to you. (Further review of V1 and V2's reports of accidents and incidents showed another facility-reported incident involving (R2) was not presented to surveyor as originally requested.) R1's care plan dated 11/18/22 revised 3/22/23 reads in part, R1 has had an actual fall due to dementia, poor balance, unsteady gait with witnessed fall on 11/17/22, unwitnessed fall on 11/26/22, witnessed fall on 12/2/22, unwitnessed fall on 12/23/22, and witnessed fall on 1/30/23. Goal: The resident will resume usual activities without further incident through the review date. Interventions: Resident will use a bed alarm to alert staff that the resident requires assistance; Resident will use geriatric chair to sit while in the dining room. MDS (Minimum Data Set) assessment dated [DATE] showed R1 as having severe cognitive impairment and required extensive assistance in all activities of daily living including transfers and mobility. Further review of MDS assessment section P (restraints and alarms) showed no usage of bed or chair alarms as per R1's care plan. Review of R1's prior MDS assessments dated 12/23/22, 1/30/23, and 2/9/23 all show R1 as requiring extensive assistance in all ADLs (activities of daily living) and again do not indicate usage of any bed alarms or chair alarms to prevent R1 from continued falling. Interview with V3 (Restorative Falls Nurse) on 4/21/23 at 2:30 PM stated, I am in charge of the falls. I am the restorative nurse and fall nurse. Surveyor asked about R1's last fall that occurred in January. V3 stated, The nurses let me know about (R1)'s fall. I found out it happened when the staff were passing dinner trays and the resident fell when she got up from where she was sitting, and she fell forward. She got stitches to her chin when she went to the emergency room and then she came back. Surveyor asked if those were the only injuries R1 sustained, V3 stated, Yes, that's what we talked about as a team in the morning meeting the next day. Surveyor asked what team she was referring to, V3 stated, The Administrator (V1), DON (V2), me, and all the department heads. We try to come up with good interventions to prevent falls and we usually refer all falls to physical therapy for working with balance and strength. Surveyor asked what fall preventative measures the facility used for high-risk residents, V3 stated, If they are unable to press the call light, we use bed alarms and chair alarms to alert staff. Surveyor asked if the facility developed a fall policy that the facility followed, V3 stated, We don't have a fall policy, we just discuss it. Surveyor asked how she conveyed to staff how to prevent falls without a policy, V3 stated, I don't know, but I will ask the DON. Surveyor asked if she was involved in training staff on how to prevent falls, V3 stated, Yes. I do the in-servicing on fall documentation, and we did it during a skill fair last month. Surveyor asked if there were any programs or symbols for staff to follow to identify residents that were at risk for falls, V3 stated, No we just discuss it, but what we last talked about with nurses was just how to document on falls. Surveyor clarified whether it was just documenting of falls when they occurred and not fall prevention that was in-serviced, V3 stated, Yes, I just talked about documentation. Interview with V12 (LPN) on 4/21/23 at 2:30 PM, V12 stated, I recall the incident with R1, that was during dinner time. I saw R1 on the other side of the hallway by the window maybe about 15 -20 feet away from me. I just saw her when she was on her way down, falling. The CNA's and I tried to get to her. I recall V9 (CNA) running to catch her before she fell too. We both tried to rush to her, but she fell , and we couldn't get to her. R1 had some minimal bleeding when she fell , and we stopped that bleeding and she was assessed. I was there and other staff members came running in to help stop the bleeding and do an assessment. Surveyor asked if there was some sort of code to prompt other nurses to come rushing into the unit, V12 stated, No. they probably just heard all the commotion. Surveyor asked if R1 only had minimal bleeding, why other staff rushed in to stop the bleeding, V12 stated, They just tried to help me because I was busy trying to do other things like call the ambulance. Surveyor asked if there was any specific staff member assigned to monitor the residents in the dining area, V12 stated, V9 (CNA) was supposed to watch R1 and the rest of the residents that day but the CNA's get too busy and have other duties. Surveyor asked if she could recall how many residents she normally took care of in the dementia unit, V12 stated, If it's a full house we usually have 33 residents and I think we were full then. Surveyor asked how many nurses and aides there were in the unit, V12 stated, There are usually 3 aides. sometimes we get agency CNA's, but there's normally 1 nurse. Surveyor asked what fall prevention measures were discussed or she did training on, V12 stated, Not too long ago we had a meeting and that was one of the subjects was about falls. Surveyor asked how she was trained to manage falls in the unit, V12 stated, There's been so many falls here. I've been here [AGE] years in the facility, and we have a lot of falls. That seems a lot, but you know, people get weak, and we discuss falls on a case-to-case basis. These residents, when they get older, they get more confused, so they will generally fall a lot. Surveyor asked what the facility did to prevent falls since, by her own account, there are a lot of falls, V12 stated, Like I said, residents have a right to fall, we can't prevent them from falling as much as we try. It's just a case-by-case basis. Interview with V9 (CNA/Certified Nursing Aide) on 4/21/23 at 3:50 PM contradicts V12's (LPN) account of R1's incident. V9 stated, I just tried to help her after she fell . I helped the nurse because she called for help. Surveyor asked what he was doing at the time R1 fell from her chair, V9 stated, In this time I passed the trays for dinner, so I was not involved in that when (R1) fell , I just heard a loud boom (V9 clapping his hands in a hard motion), but I never saw her fall . When I heard a boom and I saw her on the floor and she was bleeding on her face and the nurse (V12) was shouting help! help! but I was busy passing trays, so I did not see her fall, I just heard a loud boom on the floor. Surveyor asked if the sound he heard was an alarm, V9 stated, No she does not have an alarm, I heard her just fall because I heard just boom sound. Surveyor asked if he knows about the blue stars on the doors and when he was last trained on fall prevention, V9 stated, I don't know what that is (referring to blue stars) but we get in-service all the time, I do not remember when. Efforts to reach R1's attending physician for interview were left unanswered. Interview with V14 (Medical Director) on 4/21/23 at 2:55 PM, R1 is not my patient but I am involved with the quality assurance meetings which was just this past Wednesday of last week. We talked about falls and standard discussions. I usually ask whether a fall was preventable or could we have done something better. Sometimes falls are unpreventable falls due to psychiatric disorders, etc. Some repetitive fallers, we see if we can do something differently such as frequent rounding by staff, keeping the resident close to the nursing station, are they able to wear a helmet or use of a bed alarm or chair alarm, safety feature to the chair like anti-fallback mechanisms for the chair. We sometimes we ask families to come by more often because we can't have staff take the full burden of preventing falls. Surveyor asked whether R1 was discussed in one of their meetings, V14 stated, Yes, I recall it was a pretty significant fall with fractures and the Administrator and Director of Nursing were all involved in discussing that fall. Surveyor asked who informed her of R1's fall with fracture, V14 stated, V2 (Director of Nursing) was the one who told me because I remember we went through the standard questions and interventions and things, and I asked whether it was preventable. Surveyor asked if there was any consensus on whether the fall was preventable, V14 stated, I'm not sure about that. I just know that there were evaluations done and I believe the staff initiated some additional interventions, but specifically for R1 I am not certain. Surveyor asked whether she knew if R1 fell prior to the last significant fall, V14 stated, From what V2 told me, that was the only one. Surveyor asked if she was aware or had any further input with the falls occurring in the facility, V14 stated, We discuss falls and I believe there has been some improvement. We've implemented a lot of different interventions specific to the resident and staff should ensure that these interventions are in place to make sure they are effective. Observations conducted on 4/22/23 at 11:53 am in R1's previous nursing unit showed 30 residents in the dining area with 1 nurse (V15-LPN/Licensed Practical Nurse) present in the room and 3 aides currently assisting residents during mealtime. Surveyor asked if she knew about R1, V15 (LPN) stated, Yes, I remember her, but I was not here when she fell . Surveyor asked if R1 was one of the residents that had a chair alarm, V15 stated, Yes, but they just started using it after that last fall in January. Surveyor asked if R1 was a frequent faller, V15 stated, Oh yes, she has fallen multiple times, but she is very difficult to manage, she is always trying to sit up and get out of her chair. Surveyor asked whether someone with that history of behaviors and falling should have been on some assistive device to prevent falls, V15 stated, Yes. We should have put a chair alarm and bed alarm on her sooner. Surveyor asked about the blue stars on resident doors and what they signified, V15 stated, You know the DON (V2) was here and told me that I should know about these stars which mean the resident is a fall risk. I've been here over [AGE] years and no one's every told me about any blue stars, but he (V2) just told me I should know about the blue stars but never came back and did any in-service on them. Surveyor asked if V3 (Fall Nurse) ever came to do training on the blue stars, V15 stated, Never. On 4/22/23 at 1:55 PM V1 (Administrator) was asked about the facility fall policy referred to as their Falling Star Program, V1 stated, we don't have a policy we just have meetings about who is at high risk for falls. Surveyor asked what the blue star decal on each door signified, V1 stated, I don't really know but I will find out about it. Surveyor asked whether it was the responsibility of the Administrator to know about a falls program given that falls are discussed during their morning team meetings, V1 stated, Yes, I should know but I will find out about the program and get back to you. V1 returned a half hour later and explained to surveyor that there was no policy or procedures pertaining to the Falling Star Program referred to by V15 but was in the process of being developed. 2. R2 is a [AGE] year-old having diagnoses listed in part with aphasia following stroke, anxiety disorder, gait abnormality, and fracture of left femur. On 4/21/23 at 10:15 AM, V1 (Administrator) and V2 (Director of Nursing) were requested to present the incident reports pertaining To R1 and any other reportable incidents currently being investigated. V2 returned 30 minutes later and presented surveyor with R1's incident report but omitted presenting any report for R2. Surveyor asked again whether all reportable incidents including any ongoing facility investigations were presented to the surveyor, V2 stated, Yes, I gave you everything. A review of facility records discovered R2's fall incident not reported to surveyor as requested. Interview with V1 (Administrator) stated, I discussed this with V2 (Director of Nursing) and it was just an error on his part. Surveyor reminded V1 that V2 also did not accurately report R1's fracture along with not providing R2's incident involving a fracture and asked how V2 could make several omissions for two very significant events. V1 responded that he would discuss this V2. Facility progress notes show on 4/12/2023 04:45 V16 (RN) wrote, Note Text: Prior to the incident, at around 4:00 AM, the resident was observed sleeping on her bed. At approximately, 4:45 AM, this writer heard the resident calling for help, this writer immediately rushed to the room, and observed the resident sitting on the floor next to her bed. When resident was asked what caused the fall, resident stated that she was trying to go use the washroom, but she lost her balance and fell . Head to toe assessment completed, resident complained of pain on the left hip area, left hip was kept immobilized, and resident sent out to ER for further evaluation. On 4/12/2023 08:39 AM V17 (LPN) wrote, Nurses Note: Resident complaints of pain on left leg and unable to move and stated that she might have broken something. Resident was moaning and crying due to pain. NP informed and sent out to ER to be assessed. Pain medication administered. Family informed and verbalized understanding. Resident picked up by ambulance at 9: 15 am, resident transferred from bed to stretcher with no issues. Documents and bed hold policy given to EMT. On 4/12/2023 14:54, V17 (LPN) wrote: Nurses Note: Called hospital for updates, RN stated that resident has been admitted to hospital for left hip fracture. Care plan dated 1/2/2023 reads in part, R2 is at risk for falls related to deconditioning, gait/balance problems, CVA (stroke). Goal R2 will be free of falls through the review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Care plan dated 4/11/23 reads in part, The resident has had an actual fall: unwitnessed fall on 4/8/23, unwitnessed fall on 4/12/23. Interventions: Physical therapy to evaluate and treat when resident returns from the hospital. Bed alarm will be provided to alert staff that resident requires assistance. On 4/21/23 at 10:20 AM, R2 was observed in her room asleep laying in her bed. R2's call light was hanging from the right side of the bed on to the floor. At 12:19 PM, R2 was observed shouting out to the hall for help but did not have her call light activated. Surveyor entered R2's room and asked if she needed help, R2 tried to let surveyor know what she wanted but was unable to make clear sentences to convey what she wanted, so R2 pointed to the chair in the corner. R2's call light remained on the floor and her bed appeared to be waist high off the floor and not lowered to the ground. There were no floor mats or bed alarm that appeared to be on her bed. V9 (CNA) entered the room and had difficulty understanding what R2 wanted. R2 was able to say, Water, I want water, white water. V9 left the room and came back with a pitcher of water. Surveyor asked V9 if the call light should be on the ground, V9 went over and placed R2's call light back onto R2's bed within her reach. V9 stated, It was on her last time. Sometimes it falls down. Surveyor asked if her bed should be that high up from the ground, V9 stated, No I will lower it down. Interview with V3 (Restorative Fall Nurse) on 4/21/23 at 2:30 PM stated, (R2) fell trying to get up from her bed. The nurse assessed her, but it was an unwitnessed fall, and she sustained a hip fracture. We discussed her fall in our team meeting and we are going to have PT/OT pick her up. We placed a bed alarm, and she is able to follow command but we still caught her trying to get up herself. Even when we give her medication, she tries to get up. Surveyor asked what other interventions the facility has tried to prevent R2 from falling, V3 stated, That's all we do for her to prevent her from falling. Surveyor asked again whether there were any other preventative measures used for R2 but V3 (Restorative Fall Nurse) could not provide any other examples of assistive devices such as fall mats, call lights within reach, frequent monitoring, or low bed to prevent R2 from falling again. Review of R2's progress notes on 4/23/23 showed a 3rd preventable fall: On 4/23/23 at 04:08 am, V16 (RN) wrote, Nurses Note: She tried a couple of times to get out of bed but much better than yesterday .She followed Nurse instruction . (There was no documentation as to what R2 needed from the nurse or what instructions or interventions V16 (RN) did to prevent R2 from falling out of bed.) On 4/23/23 at 8:00 AM, V7 (LPN) wrote, Incident Note. Prior to incident 7:30 a.m. resident was observed sleeping on her bed and bed set at lowest position with call light within reach and with bed alarm. Around 8:00 a.m. bed alarm went off and staff member rushed into the room and saw resident on the floor in an upright sitting position next to her bed. Staff alert this writer that the resident was observed on the floor. Writer quickly went to the room to check on resident and asked resident what happened, and resident stated she tried to get out of bed to go use the bathroom but felt weak and lost balance and fell . Head to toe assessment completed. No new redness or swelling noted, no shortening on any extremities. Resident verbalized pain in the back of her head. No bruise or lumps felt on back of head upon assessment at that time. Resident appeared agitated and anxious. No loss of consciousness. Able to move all extremities at baseline without complain of pain. Tramadol and Xanax given. Vital signs taken; Family notified and verbalized understanding. NP notified with orders to send the resident via 911 to hospital for further evaluation. 3. R3 is a [AGE] year-old diagnosed in part with Alzheimer's Disease, Chronic obstructive Pulmonary Disease, injury of the face, and traumatic hemorrhage of cerebrum. R3's care plan with multiple dates reads in part, R3 is at risk for falls related to gait/balance problems. On 2/19/21-resident fell in her room with laceration on top right forehead noted. sent to hospital for evaluation. On 10/23/21: Unwitnessed fall resulting in hematoma to chin. Sent to ER and returned without new orders. On 10/23 21: Witnessed fall. On 3/29/21 Witnessed fall; On 5/25/22 Witnessed fall, On 10/8/22-Unwitnessed fall; and on 4/8/23 Unwitnessed fall. Interventions: Resident will be close to the nurse's station for close monitoring; wheelchair axle lowered to ensure resident is sitting at the lowest position of the wheelchair; the resident uses chair and bed electronic alarm. Ensure the device is in place as needed. A facility incident written by V18 (RN) dated 4/8/23 shows in part, Prior to incident at around 2:50 PM, the resident was sitting on her wheelchair at the dining room. At approximately 3:00 PM, other nurse on duty observed the resident trying to get up from her wheelchair and ran to her but could not get to the resident on time to prevent the fall. Nurse on duty immediately went to assess the resident. Resident was laying on her right side and noted bleeding by her head. Head to toe assessment done. Applied pressure dressing and cold pack to stop the bleeding. Called 911 to send to the ER for further evaluation. Facility incident report does not indicate whether a chair alarm activated nor identified the other nurse on duty. Interview with V2 (Director of Nursing) on 4/21/23 at 10:15 AM stated, V18 (RN) wrote the incident report but she was not the one that observed this fall. Surveyor asked if V18 didn't observe the fall, why she made the entry in the nursing notes, V2 stated, That's just how we do incidents here. Surveyor asked if R3 should have a chair alarm to alert staff if she stood up from the chair, V2 stated, She should but I see that V18 didn't put that in her report, so I don't know whether she did or not. On 4/11/23, R3 was readmitted back to the facility. V19 (RN) wrote in part: 4/11/2023 15:00 Admission Summary: readmitted this [AGE] year old, female white, from hospital per stretcher accompanied by 2 paramedics with the diagnosis of Frontal Lobe Hematoma, alert with periods of confusion and forgetfulness, physical assessment done, abdomen soft and non-tender with colostomy bag on right mid abdomen intact and patent, lungs field clear and no congestion, old bruise on right forehead with skin tear with 4 stitches, dry and clean , bruise on right eye. Interview with V3 (Restorative Falls Nurse) on 4/21/23 at 2:30 PM stated, (R3) is wheelchair bound and she was in her wheelchair at the time of this incident and she tried to get up and she fell because she doesn't have good balance. We had a chair alarm for her to prevent her from falling. V5 (RN) happened to be in same hallway when she attempted to prevent the resident from falling but the resident fell to the right side of forehead. Surveyor asked what fall preventative measures the facility used for R3, V3 stated, We tried to encourage her to sit by the nurse's station because she moves herself and we try to get more supervision. Surveyor asked whether she was present during R3's fall incident, V3 stated, No she fell over the weekend, so I did not see it, it was just reported to me and we talked about it in our morning meeting. Surveyor asked if she knew whether the chair alarm was activated for R3 as there is no indication of it in the incident report going off to warn staff the resident was about to fall, V3 stated, I don't know for sure, I just know staff should have it on when R3 is in her wheelchair. Surveyor asked whether R3's latest fall was witnessed or unwitnessed as the care plan listed the fall as an unwitnessed fall, but the incident report showed it was witnessed, V3 stated, I don't know. 4. R4 is a [AGE] year-old cognitively impaired resident with diagnoses of dementia, unsteadiness of feet, nondisplaced fracture of 5th cervical vertebra, fracture of shaft of humerus (left arm), and fracture of left rib. R4's care plan showed previous falls: 15 unwitnessed and 2 witnessed falls. Care plan reads in part, (R4) is at risk for falls related to overactive bladder, osteoporosis, dementia, anxiety, major depression, and partial hearing loss. Interventions: The resident will be provided with a helmet to prevent injuries; Resident will use a bed alarm to alert staff that resident requires staff assistance; Offer and assist the resident to use the bathroom at night at least every 2 hours. Resident was provided visual reminders to call for assistance with activities of daily living; the resident uses chair electronic alarm. ensure the device is in place as needed. Interview with V3 (Restorative Fall Nurse) on 4/21/23 at 2:30 PM stated, When R4 last fell (3/31/23), She tried to get up from the wheelchair. She got another cut to her right side of her head, and she was sent out 911. She received sutures. Surveyor asked how many falls R4 had and what the facility was doing to prevent further falls, V3 stated, I know she fell a lot but we are using a geriatric chair instead of a wheelchair, we tried to use a geriatric chair and there is an alarm on her geriatric chair. I think we just put her on a geriatric chair after this last fall. A facility policy dated March 2018 titled Assessing Falls and Their Causes does not address fall prevention but shows policy and procedures for assessing falls after they've already occurred. This facility policy reads in part, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. There was no policy or procedures for the facility's Falling Star program for residents considered at-risk for falls. According to V1 (Administrator), the program policy had not yet been developed.

Based on observation, interview and record review, the facility failed to follow its wound care policy and procedures and individual resident care plans to prevent and manage facility-acquired pressure ulcers for 1 (R5) of 3 residents reviewed for pressure ulcers from a sample of 3. These failures resulted in R5 sustaining 2 facility-acquired pressure ulcers to the sacrum and left ischial tuberosity (pelvis area). Findings include: On 4/27/22 at 11:20 AM, surveyor requested a wound report from V2 (Director of Nurses/DON). The report showed all pressure ulcers that were actively being treated by the facility. Shown on this report were two facility-acquired pressure ulcers for R5: #1. Sacrum; facility-acquired pressure ulceration; active status, clinical stage 4. #2. Left Ischial tuberosity; facility-acquired pressure ulceration, active status, clinical stage unstageable. Facility wound assessment detailed report of R5's wounds conducted by V7 (Wound Nurse Coordinator) dated 3/9/22 showed the sacrum wound measured 3.20 centimeters in length, 3.00 centimeters wide, and 0.30 centimeters depth. Undermining was present in the wound (pocket or eroded skin underneath wound edges), and an overall area of 9.60 centimeters. A second facility wound assessment detailed report for R5's other facility-acquired pressure ulcer dated 3/9/22 showed the left ischial tuberosity measured 1.50 centimeters length, 0.80 centimeters wide, and 0.10 depth, with a clinical stage 3. R5 is an alert and oriented [AGE] year old resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/27/22 at 11:40 AM, R5 was observed lying on her back with both feet encased in blue-colored boots propped up on the foot board of the bed. R5 stated, Are you here to help me? Surveyor identified self and asked if R5 could use the call light to ask for help. R5 stated, Good luck with that. Surveyor asked R5 to clarify. R5 stated, I'm very uncomfortable on my back, and I've been on it since this morning. Surveyor asked if she knew who her nurse and aide were. R5 stated, I don't know their names; they don't even have identification on them or even tell me who they are. I see them once and then they disappear. Surveyor asked if she is ever assisted in repositioning in bed. R5 stated, No, you've got to be kidding me. I've already told my sister and brothers about this problem, and they actually can watch me on that thing (pointing to an electronic virtual assistant). I can't do much myself, and I need someone to turn me. I can't do it at all. V5 (Registered Nurse/RN) came into the room and asked R5 if she needed assistance. R5 stated, Yes I need to get turned. Surveyor asked V5 when she last came in to see R5. V5 stated, I saw her earlier when I got in around 7-7:30 (AM), and I gave R5 her medications. Why; is there a problem? Surveyor asked who R5's aide was today. V5 stated, I think it's V6 (Certified Nursing Assistant/CNA) today. Do you need her? Surveyor asked V5 if she knew when R5 was last repositioned. V5 stated, I'm not sure, but I can ask her CNA. Surveyor requested to view R5's wounds on her backside and V5 (RN) called in V6 (CNA) to assist in turning R5 to allow surveyor to view the wounds. V5 stated, This first wound is the left ischial stage 3 and it's facility-acquired. It's stable, and it was last seen by the wound doctor last week, I think. The other wound is on her sacrum. It is a stage 4 and also facility-acquired. It has undermining. Surveyor asked when the wound dressings were last changed as there were no apparent markings or dates on the dressings to signify when they were last changed. V5 stated, We no longer initial and date the wound dressings according to our corporate consultant. Surveyor asked how she knew the wound care was done if the dressings were not dated and initialed by the nurse conducting the dressing change, V5 stated, I don't know, but I know that we have not been marking the dressings for a while now. Surveyor asked who did the dressing changes normally. V5 stated, That would be the wound nurse (V7), but she has been off duty for a week. I think she's due back today because they called her in. Surveyor asked if the dressings appeared clean and dry. V5 stated, No, they need changing. I was going to do that today, but I was told the wound nurse was coming back so I didn't do them. On 4/27/22 at 11:40 AM, V15 (Caregiver) stated, I have been (R5)'s caregiver, and I am just here to be her companion. I am here most of the day and I have to ask the CNAs here to come in and help her, because they expect me to do things for her, and I can't do that. Surveyor asked if she ever sees the aides come in the room to reposition (R5). V15 stated, Sometimes you'll get an aide to come in and turn R5. She needs two people but there's just one (aide) that does it. Surveyor asked how frequently the aides or nurses will come in. V15 stated, I'll see the nurse once maybe in the morning to give medications, but then I don't see them until the next shift comes. R5 mostly has problems getting someone in to see her when I'm gone. R5 nodded in agreement and stated, Yes, in the evening and especially at night. R5's Minimum Data Set (MDS) dated [DATE] shows R5 with a Brief Interview for mental Status (BIMS) score of 12, indicating mild cognitive impairment. This same MDS shows R5 requiring extensive assistance in bed mobility (turning and repositioning in bed) and requiring a minimum of 2 persons to accomplish this task. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 4/27/22 at 12:28 PM V7 (Wound Nurse) stated, I was off for 6 days and I got a call back from V2 (DON) to come back because public health was here. Surveyor asked about the wound dressings policy. V7 stated, I was told by our wound consultant that we were not supposed to label the dressings of when they are changed due to infection control. Surveyor asked how labeling the wound dressing was an infection control issue. V7 stated, I guess because when you use a pen to mark the dressing before putting it on the wound, it could be an infection control problem. Surveyor asked if this was also true of not labeling any pain patch medications or other transdermal medications applied on a patient. V7 stated, I see what you mean. I don't know why then, but I will let our corporate know. On 4/27/22 at 1:00 PM, V2 (DON) informed surveyor that they were going to start labeling of wound dressings, and the nurses would initial the dressing changes to denote when these wounds were treated and when wound dressings and bandages were changed. On 4/27/22 at 4:30 PM, surveyor observed wound care for R5 with V7 (Wound Care Nurse) and V9 (Wound Doctor). R5 was turned to her right side to reveal an open area appearing as a hole on her sacral area. V9 performed a debridement procedure with a scalpel to remove slough and dead necrotic skin around the area of the wound. Below the sacral area was feces in between R5's buttocks which was not cleaned prior to the procedure. V9 explained to surveyor, I'm lightly [MEDICATION(S)] the area with this scalpel. Surveyor asked if there was any undermining or tunneling of the wound. V9 stated, There is no tunneling, but there is undermining at 7:00 o'clock to 3:00 o'clock, and it approximately undermines 1.8 inches in. As V9 finished the debridement procedure, V7 (Wound Nurse) finished the dressing change on the wound and surveyor asked about the feces that was present prior to the doctor starting the procedure. V7 stated, I don't know; I'm not sure why she wasn't cleaned up before V9 started the debridement. V7 called in a nursing aide (V13) to clean R5. Surveyor asked V13 (CNA) why R5 wasn't cleaned up prior to the procedure. V13 stated, I don't know. (R5) is not my resident. I was just called to come and clean her up, but R5 is V14's (CNA) resident. Surveyor interviewed V9 (Wound Doctor) after the debridement procedure about the absence of labelling and initialing of wound dressings when they are conducted. V9 stated, I don't decide on when the bandages/dressings are signed off by the nurse; that's a facility decision. Surveyor asked the importance of dating the wound bandages. V9 stated, I would think that it's so the nurse conducting the dressing change knows that the wound was treated and dressings were changed. However, that is not my decision to make. Surveyor asked about the importance of turning and repositioning. V9 stated, That is of utmost importance of off-loading to relieve pressure off the wound and pressure points. I mention this in my assessments and orders. On 5/2/22 at 11:20 AM, V7 (Wound Nurse) was asked about her wound assessments for R5. V7 stated, I always write on the wound assessments to turn and reposition and to off-load the site and we continue with her air loss mattress. It's the wound doctor's order and we care plan this. Surveyor asked how they verified that this was being carried out. V7 stated, I ask the CNAs directly and they tell me 'Yes.' Surveyor asked how often R5 needed to be repositioned while in bed. V7 stated, R5 needs to be repositioned at least every 2 hours or as needed. That's the order from the doctor. Surveyor asked if there was any documentation for this. V7 stated, I know that it's in the TAR (Treatment Administration Record). TARs for R5 were provided to the surveyor which showed Frequent turning and repositioning at least every two hours and appropriate every shift for immobility. This same TAR shows an electronic signature by the nurse once per shift, denoting the resident was repositioned once per eight-hour shift. R5's wound care plan reads in part: (R5) has stage 4 pressure ulcer to sacral area; Diagnosis [CONDITION(S)] and immobility; incontinent of bowel, [CONDITION(S)]. 3/2/22 left hip unstageable. Goal: (R5) pressure ulcer to sacrum area and left ischial area will show signs of improvement. Interventions: Administer treatments as ordered by physician and monitor for effectiveness with each dressing change. Apply off-loading device while in bed. Assess/record wound healing; Observe dressing to ensure it is intact and adhering; Teach resident the importance of changing positions for prevention and decline of pressure ulcers; Encourage small frequent position changes; The resident requires pressure prevention device air mattress; Turn/reposition at least every 2 hours or requested by resident more often as needed. On 5/2/22 at 2:40 PM, R5 was observed in bed lying on her back. Surveyor asked R5 if anyone came to reposition her in bed. R5 stated, Well my caregiver was here, and I can tell you they came in twice and only one aide came to help me. I need two people because I can't do it myself and I keep telling them that. I guess I'm lucky they even come in now since you've been here (referring to surveyor). Facility policy revised April 2022 titled Pressure Ulcers/skin Breakdown Protocol reads in part (but not limited to): The nursing staff and practitioner will assess and document an individual's significant risk factor for developing pressure ulcers; for example immobility, recent wight loss and history of pressure ulcers. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width, present dates or necrotic tissue; pain assessment; resident's mobility status, current treatments, including support surfaces and all active diagnoses. Treatment/Management: The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents. Label tape or dressing with date, time, and initials. Place on clean field.

Based on interview and record review the facility failed to ensure proper transferring of a resident from bed to shower chair resulting in resident sustaining a deep laceration of right ankle that required hospital visit for suturing. This affected one (R1) of 3 residents reviewed for safe transfer in a total sample of 9. Findings include: On 2/15/22/ at 8:31am V7 (Family member) said that on 1/27/22, R1 was injured on R1's foot while being transferred to the shower chair by 2 staff. V7 said no mechanical lift was involved. V7 said R1's foot/ankle was gashed and R1 was sent to the hospital. R1's foot required 12 stitches and was sent back to facility. V7 said R1's foot kept bleeding over the next 3 days. On 1/30/22 at 8:15am, V7 saw R1's foot heavily bleeding and R1 was sent to the hospital again and was admitted . R1 was admitted to facility on 1/16/22 with diagnoses including but not limited to COVID, difficulty walking, muscle/generalized weakness, type 2 diabetes mellitus, unsteadiness on feet, [CONDITION(S)], [CONDITION(S)], hypertension, dependence on oxygen. Review of R1's care plan did not include an Activities of Daily Livings (ADL) care plan, including transfer. R1's care plan was not updated for transfer after the incident. On 2/17/22 at 10:16am V19 (Restorative Nurse) said that he did not complete R1's ADL care plan. V19 said for some reason he just missed it. V19 said that he does not know the facility's policy in formulating and revision of resident's care plan and said he will get back to surveyor regarding the policy. V19 said that he did R1's MDS (Minimum Data Assessment) admission assessment dated [DATE], which documents Section G: Transfer: 1. Self-performance: coded 3 = extensive assistance, 2. Support: coded 3 = 2 + person physical assist. On 2/17/22 at 10:30am V6 (Nurse Consultant) said that initial resident care plan is formulated within 24hrs, and comprehensive care plan is developed within 7 days after the completion of the MDS assessment. On 2/16/22 at 11:16am V8 (Certified Nursing Assistant/CNA) said that he took care of R1 on the day of incident. V8 said that R1 is alert and oriented x 3, able to verbalize needs to staff. V8 said that during R1's transfer from bed to shower chair with V18 (CNA student) R1 sustained an injury to R1's right ankle, and R1 was sent out to the hospital for suturing. V8 explained that R1 is a 1 person assist during transfer, and V8 just asked V18 CNA student to hold the shower chair while he physically transferred R1. V8 does not know what happened and noticed blood on R1's right foot and he called V3 (Assistant Director of Nursing/ADON) to assess. V8 said that he was not given transfer training inservice after the incident. On 2/16/22 at 3:05pm V2 (Director of Nursing/DON) said that R1 is a 2 person assist, but V8 (CNA) can handle R1 by himself. V2 said that they removed/discarded the shower chair when surveyor asked to see the shower chair. Both V8 (CNA) and V18 (CNA student) were given instruction regarding safe transfer after the incident. R1's incident report dated 1/27/22 at 10am documented by V2 (DON) indicated R1 was transferring from bed to shower chair. R1 pivoted from bed to shower chair. R1 stated My right knee buckles sometimes. When sitting down R1 sustained a right ankle open area. Pressure was immediately applied. Bleeding ceased. Wound cleansed and wrapped with kerlix. R1 sent out to the hospital for further evaluation. R1 returned to facility. Final report: R1 will be screened by therapy for transfer and strengthening. R1's hospital emergency department report dated 1/27/22 provided by V2 (DON) indicated: The patient was transferring from bed to chair to go have a bath when she slid and struck the right ankle on the corner of a chair. There is a 6cm and a laceration on the anterior and lateral aspect of the right ankle just superior to the joint line. There is no penetration into the joint or through the fascia. Laceration repair 12 sutures. Diagnosis: Ankle laceration injury. Hospital Triage report dated 1/27/22 from V3 (ADON) indicated R1 is alert and oriented x4, reports being assisted by staff to shower chair, right ankle got caught. Laceration noted to right foot approx. 5x1x0.5cm. Wrapped in gauze, bleeding controlled. R1 denied chest pain, SOB (Shortness of Breath). R1's baseline 02 (oxygen) is at 3LPM (liters per minute) NC (nasal cannula) in use. R1 has history of Hypertension, Diabetes, CHF, [CONDITION(S)] and on [MEDICATION(S)]. Surveyor informed V2 (DON) that her incident documentation is inconsistent with report given by V3 (ADON/nurse on duty when the incident happened) to the hospital. The report given by V3 (ADON), V18 (Student CNA) and V14 (Nurse Practitioner) were consistent. The incident report submitted by V2 (DON) to State Agency did not have measurement and description of the deep laceration on R1's right ankle. The incident report also did not indicate that a procedure was done at the hospital. On 2/17/22 at 7:01am V18 (CNA Student) said that she has observed and helped CNAs do mechanical lift transfers for R1. V18 stated V18 does not know why they did not use a mechanical lift transfer for R1 on 1/27/22. V8 (CNA) did not explain to her why they did not use the mechanical lift. V18 (CNA student) said she assumed it is faster and quicker using physical lift. V18 said, V8 asked me to hold the shower chair while V8 transferred R1 from bed to shower chair. R1 moved her foot and got caught at shower chair wheels. V18 said they did not notice it until they saw her right ankle was bleeding. They called V3 (ADON) who was the nurse in the unit. R1 did not complain of pain, and she did not feel the injury because she was diabetic. V18 said, R1 is on a blood thinner medication and that's why she bleeds a lot. V18 stated she was not given in-service training for transfer technique by V2 (DON) after the incident. V18 said she does not have her clinical instructor in the facility, and she just report to V2 (DON) if she has any questions. V18 said that she started her CNA class last 1/3/22. On 2/16/22 at 1:35pm V14 (Nurse Practitioner) said she saw R1 on 1/27/22 after the incident. V14 said nursing reported that morning while R1 was getting a shower her right foot was caught by shower chair. A deep laceration at right ankle was present without active bleeding, pressure dressing was applied. R1 denied acute pain or distress. R1 was sent out to the hospital for suturing. R1 returned from hospital after suturing on the same day. V14 saw R1 on 1/28/22 for follow up. Nursing reported bleeding from the suture site at right ankle, manual pressure applied for 30 mins and applied pressure dressing. Blood thinning medication was held. R1 was sent again to hospital due to suture site bleeding. V14 said R1 needs a minimum of 2 person assist for transfer. R1's Physician order sheet for January 2022 indicated: 1/27/22 - sent to Emergency for laceration in her right ankle. 1/28/22 - send to emergency room (ER) for treatment and eval due to Right Lower leg laceration ankle, and 1/30/22 - send to hospital ER for eval due to Right ankle stiches dehiscence. On 2/17/22 at 11:25am V20 (Therapy Director) said that she has provided therapy treatment with R1 several times. V20 said R1 needs maximum assistance with 2 person assist for transfer. R1 should not be transferred or be lifted with 1 person only. V20 said that no one should do the transfer until they know how R1's legs work or if R1 is strong enough to stand. V20 said that they reported to nursing that R1 is a maximum assist with 2 or more persons. V20 cannot remember the name of the nurse she gave report to. V20 said she suggested a mechanical lift for safe transfer. Facility's Care Plan policy documents: Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Interpretation and implementation: 12. The comprehensive, person-centered care plan is developed within 7 days of the completion of the required comprehensive assessment (MDS). 13. Assessments of resident are ongoing and care plans are revised as information about the residents and the residents' condition change.

Based on observation, interview, and record review, the facility failed to follow the wound care policy and procedures and individual resident care plans to prevent and manage facility-acquired pressure sores for three (R1, R2, R3) of three residents reviewed for pressure sores. These failures resulted in all three residents sustaining avoidable stage 3 and 4 pressure ulcers to their sacral areas. Findings include: 3/5/21 at 11:50 AM, surveyor requested a wound report from V2 (Director of Nurses) who provided a list that showed R1, R2 and R3 with facility-acquired pressure ulcers to their sacrum. R1 is a [AGE] year old resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An initial facility wound assessment submitted by V16 (Wound Doctor) dated 6/2/20 states, At the request of the physician, a thorough wound care assessment and evaluation was performed today. R1 has an unstageable due to necrosis (dead tissue) sacrum for at least 1 day duration. The patient verbalizes pain with a score of 5 out of 10. Past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . No relevant family history identified which includes a negative history for immunosuppressive conditions, collagen-vascular disease and bleeding disorders. The most current facility wound assessment submitted by V16 dated 2/24/21 states, At request of the referring provider, a thorough wound assessment and evaluation was performed today. (R1) has a stage 4 pressure wound sacrum for at least 256 days duration. There is moderate serous exudate. Wound size: 3.2 x 2.8 x 0.3 centimeters. Undermining: 1.6 cm at 12:00 o'clock. Plan of care reviewed and addressed. Recommendations: Reposition per facility protocol; off-load wound. 3/5/21 at 12:00 PM, R1 was observed in bed on her back with a sheet partially draped over her body but exposing her incontinence brief that appeared bunched up over her private area. V8 (RN) was asked if she was the nurse taking care of R1, V8 stated, Yes, I have these residents in this hall. Most of them are on isolation because they just came from the hospital. Surveyor asked about R1 and the care provided for her wounds , V8 stated, I'm not sure about her, we don't do wound care for her because the night shift does the treatments. Surveyor asked whether R1 was gotten up from bed or dressed since it was already noon, V8 stated, She stays in bed most of the time. Surveyor asked whether she was the regular nurse that worked the unit where R1 was in, V8 stated, Yes, I'm the usual nurse. 3/5/21 at 2:20 PM, R1 was observed in the same position on her back. V3 (LPN Treatment Nurse and ADON) was asked to see R1's treatment and to describe the wound. V3 called over an aide for assistance and V12 (CNA) came and assisted to turn R1 to her side to let surveyor observe the wound. Once R1 was on her side, V3 took off R1's incontinence brief and slowly peeled off a bandage dated 3/5/21. V3 stated, This is usually done by the night nurses around 6 AM before they leave. Surveyor clarified whether he was the treatment nurse, V3 stated, I am but I just go around with the wound doctor and when he comes during the week but it's the night shift nurses that mostly do the wound care. V3 described the wound and stated, There is border gauze and calcium alginate [MEDICATION(S)] placed on the wound. There is some slough and undermining and it is bright and beefy red with little maceration. Surveyor asked the approximate size and location of the wound, V3 stated, It's round and located on her sacrum. I don't know the exact measurements because I don't have the notes in front of me but it is round and I would agree that it is the size of a golf ball. Surveyor asked whether the wound was from the hospital or from the facility, V3 stated, It's facility-acquired but it was here before I started in November. R1's care plan dated 12/22/20 states in part (but not limited to): (R1) has a stage 4 pressure ulcer to sacral area; Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Goal: R1 pressure ulcer will show signs of healing and remain free from infection. Interventions: Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. R2 is [AGE] year old resident with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility wound report provided to surveyor shows R2 with an active facility-acquired Stage 4 pressure ulcer on her sacrum first identified on 7/23/20. Latest wound note record dated 2/24/21 from V16 (wound doctor) states, Stage 4 Pressure Wound Sacrum measurements 1.0 x 0.4 x 0.2 cm with wound duration of >190 days. Plan of care reviewed and addressed. Recommendations: Reposition per facility protocol; off-load wound. R2's Care plan dated 1/25/21 states in part (but not limited to): (R2) has pressure ulcer stage 4 to sacrum; related to bowel and bladder incontinence and was resistive to care at times (has staff preferences), wants to be bedbound (refused transfer); Goal: The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness; Assess/record/monitor wound healing as ordered; Measure length, width and depth where possible.;Assess and document status of wound perimeter, wound bed and healing progress;Report improvements and declines to the MD; Avoid positioning the resident on on her back/sacrum pressure point. 3/5/21 at 11:55 AM, R2 was observed asleep in bed on her backside. At 1:10 PM, R2 remained on her backside and with her eyes closed and appeared still sleeping. V4 (RN) was asked about R4's wound(s), V4 stated, I don't know, she doesn't like anyone to bother her. Surveyor asked about R2's care or whether staff needed to help her to get dressed, V4 stated, I don't know, she always stays in bed. 3/5/21 at 2:50 PM, R2 was observed in bed on her backside. There were no pillows or wedges observed on her bed to ensure she was not lying directly on her back/sacrum area as per her care plan dated 1/25/21. R3 is a [AGE] year old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility wound report provided to surveyor shows R3 with an active facility-acquired stage 3 pressure ulceration to her Sacrum identified on 4/28/20. Latest wound note dated 2/24/21 from V16 (wound doctor) states, Stage 3 Pressure Wound Sacrum measurements 0.6 x 0.5 x 0.2 cm with wound duration of >270 days healing. Plan of care reviewed and addressed. Recommendations: Reposition per facility protocol; off-load wound. R3's care plan dated 11/20/20 states in part (but not limited to): (R3) has stage 3 pressure ulcer to her sacrum; on treatment plan; assistance provided to daily care; 2/4/21 new order from Dr for wound treatment; R3 pressure ulcer to her sacrum will show signs of healing and remain free from infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness; Assess for pain level; Administer pain medication as ordered before treatment plan as needed; Monitor/document for side effects and effectiveness; Assess/record/monitor wound healing; Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Avoid positioning the resident on her sacrum. Facility nursing note written by V3(ADON/treatment nurse) shows on 3/3/2021 at 2:41 PM, Skin/Wound Note Late Entry: Resident is a [AGE] year old female, seen by doctor (V16) and writer. Seen for pressure wound to sacrum. Wound remains stable, L: 0.4 W: 0.6 D: 0.2. Dressing changed; wound bed covered with collagen sheet, packed with alginate w/silver, covered with island dressing. Will continue to monitor wound and continue current treatment plan. 3/5/21 at 12:10 PM, V10 (LPN-Licensed Practical Nurse) was asked whether there were any residents under her care with any wound care needs. V10 stated, I don't think we have anyone here. I know we have one isolation but I don't think she has any wounds. Surveyor asked if there were any wound treatments or care conducted by nursing staff in the dementia unit that R3 was on, V10 stated, I'm not aware of any. We have residents that wander but I don't know because I just started four months ago. 3/7/21 at 11:34 AM, V2 (DON) was asked what the facility's wound protocol was for the facility, V2 stated, I'm sorry I don't know what that is. That would be from V3, the assistant director of nurses since he's in charge of that. 3/7/21 at 11:37 AM and again at 1:30 PM, V16 (Wound Doctor) was paged for interview but could not be reached nor returned surveyor's messages. 3/7/21 at 12:38 PM, surveyor asked V2 about R1, R2 and R3's wounds to show whether any of their wounds were determined unavoidable by the physician, V2 stated, I'm not sure we have anything to show that but we've been working with our team and we do discuss the wounds to try to heal them. I know that the there's increased repositioning that we do and the nurses should be documenting that in the computer. Surveyor asked where nurses demonstrate and record the repositioning mentioned since it could not be found in the records, V2 stated, It's been a challenge to get these nurses to do this charting since we've gone computerized last November so I can't really say it's done, you're right. I will have to address this with them again. Facility policy revised 4/2018 titled Pressure Ulcers/Skin Breakdown - Clinical Protocol states in part (but not limited to): The nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment;c. Resident ' s mobility status;d. Current treatments, including support surfaces; and e. All active diagnoses. Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. a. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. b. Current approaches should be reviewed for whether they remain pertinent to the resident/patient ' s medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker.

Based on interview and record review the facility failed to ensure a resident was free from abuse for one (R2) of three residents reviewed for abuse in a sample of ten. This failure resulted in R2's left hip being fractured. Findings include: The facility's Abuse Prevention Program undated documents, Abuse Prevention Policy: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The facility's Final Report of Incident dated 9/30/2020 documents, Investigation: A complete investigation was done regarding the residents discoloration bruised area which resulted in a [MEDICAL CONDITION]. Five nurses and two Certified Nurses Assistants/CNA's and as well as one agency CNA were suspended pending investigation after multiple interviews regarding the timeline of the injury. During the investigation, it was revealed that there were multiple attempts for a indwelling catheter insertion on 9/22/20 in which the resident became uncooperative and resistant towards the procedure. During the procedure V11/CNA and V12/CNA were told by V7/ Licensed Practical Nurse/LPN to hold the right hand and left leg of (R2) in order to insert the catheter. Multiple attempts were done by V7/LPN without successful placement. V7/LPN then asked V13/LPN to come and try insertion of the catheter. V13/ LPN came to the room, attempted to insert catheter once but met resistance she stopped immediately. V13/LPN then stated to V7/LPN not to attempt again. V14/LPN then came to the room to attempt catheter insertion with the presence of V7/LPN. V11/CNA and V12/CNA. V14/LPN attempted once and met the same resistance and therefore stopped the procedure and told V7/LPN not to attempt again. V12/CNA was interviewed and stated (R2) was not cooperative and resistive towards the procedure. V11/CNA stated she held the residents right hand and another CNA held residents left hand and leg. V11/CNA was interviewed and stated she had to hold resident's leg as means for the assigned nurse to place the catheter. V11/CNA stated she held the resident's leg as resident was not cooperative and very stiff. V15/CNA was interviewed and stated that when she started her shift, she noticed that (R2) was exhibiting signs of pain which was unusual behavior for this resident. V15/CNA expressed her concern to V8/Registered Nurse/RN who stated that it is due to the resident having multiple attempts at catheter insertion earlier in the day. V15/CNA stated she assisted V8/RN at the beginning of her shift by holding the left foot of (R2) while V7/LPN held the left leg/thigh in order to re-attempt catheter insertion which was then successfully. The Facility received orders to complete X-Ray for (R2's) that identified questionable fracture of left hip. On 9/25/20 (R2) was noted with significant change of increased pain and swelling and physician order [REDACTED]. V8/RN called hospital for resident's status and was informed that (R2) was admitted with [DIAGNOSES REDACTED]. Conclusion: Thorough investigation was completed. Based on the investigation it is concluded, the left [MEDICAL CONDITION] and discoloration was likely caused by multiple attempts to reinsert (R2's) catheter. Staff members that are currently suspended pending investigation will be re-educated on the Abuse Policy and Abuse Reporting Procedure, residents Rights with emphasis on resident's right to refuse treatment, change in resident condition/status policy and indwelling catheter insertion for nurses. On 1/2/21 at 12:00 PM V2/Director of Nurses stated, So here is the report along with the in-services. It appears the resident's hands and legs were held by staff to place a catheter and it took several attempts. The staff involved were suspended and then all were re-educated on resident rights to refuse treatment, catheter insertion, abuse and reporting abuse. It was determined that the left [MEDICAL CONDITION] occurred during the catheter insertion.

Based on record review and interview, the facility failed to supervise 1of 5 residents reviewed for wandering ( R2 ) in the sample of 10, which resulted to an aggressive, agitated and territorial resident (R3) pushing R2, causing R2 to fall. R2 sustained a laceration to the lip, fractured right orbital floor, subarachnoid hemorrhage, traumatic subdural hematoma, and multiple contusions. This failure resulted in an Immediate Jeopardy when on [DATE], R2 wandered into R3's room which resulted in R2 and R3 pushing each other, and causing R2 to fall to the floor sustaining multiple injuries. R2 was transferred to the hospital and later discharged back to the facility on [DATE]. On [DATE] R2 was transferred back to the hospital due to lethargy and vomiting. R2 subsequently expired at the hospital on [DATE]. The facility did not supervise R2 to prevent her from wandering into R3's room after being left unsupervised in the small dining room. R3 has a documented history of verbal and physical aggression to other residents, who wanders into R3's room. The facility did not provide immediate supervision of R3 after the altercation with R2, to prevent potential risk of aggression towards the other residents on the unit. The Administrator ( E1 ) was notified of these failures on [DATE] at 1 PM which resulted in an Immediate Jeopardy. While the Immediate Jeopardy was corrected on [DATE], the facility remains out of compliance at severity level 2, because the facility has yet to inservice the new hires on all shifts, has yet to assess if new interventions and policies are effective on the possible affected residents, and the facility's evaluation of the new plan of care has yet to be conducted Findings include : 1) R2 has a [DIAGNOSES REDACTED]. R2's SOAP note dated [DATE] indicated that R2 is disoriented to place and time, does not follow commands, long term and short term memory are poor, attention span is limited to poor, thought process is loose, thought content is confusional, and insight and judgment are poor. It also said that R2 is confused, and is often walking the floor. R2's care plan dated [DATE] and [DATE] also identified her as a wanderer. They mention that R2 exhibits confusion and disorientation, as evidenced by inability to find own room and locate other areas of the facility. During the following interviews, all of these staff below, indicated that R2 is a wanderer, and would go to other residents' rooms, including R3's : a) E8 ( CNA/ Certified Nurse Aide) - interviewed on [DATE] at 2:00 PM b) E5 ( Rehab Aide ) - interviewed on [DATE] at 2:15 PM c) E4 ( ,[DATE] nurse ) - interviewed on [DATE] at 1:16 PM d) E9 ( 11-,[DATE]-3 CNA ) - interviewed on [DATE] at 1:50 PM e) E3 ( ,[DATE] CNA ) - interviewed on [DATE] at 2:15 PM f) E6 ( ,[DATE] nurse ) - interviewed on [DATE] at 4:30 PM R3 has a [DIAGNOSES REDACTED]. Facility record dated [DATE] shows that R3 is 5 feet 2 inches tall and weighs 181.2 lbs. R3 is heavier than R2. Review of the following nurses notes showed that R3 has a history of being agitated, territorial, and verbally and physically aggressive towards other residents who wander in R3's room, and those whom R3 thinks, are going towards her room : a) [DATE] at 10:00 AM, R3 pushed R7 out of her room. b) [DATE] at 6:00 PM, R3 pushed an unidentified resident out of her room. R3 was also heard yelling at a female resident who wandered in to her bedroom. c) [DATE] at 7:30 PM, while standing in the hallway, R3 pulled another unidentified resident's collar saying " You're not going in my bedroom." When redirected, R3 became angry and became verbally abusive to staff and other resident. d) [DATE] 5:45 PM, R3 became angry and agitated when she found another resident R7 inside her room. At 5:50 PM, R7 stated that R3 pushed her and she ended up sitting on the floor. R3 stated that " She's terrible. She's always going in my room." e) [DATE] 11:00 AM, R3 was very impatient and got off even from simple noise or distraction, and gets more agitated when redirected. f) [DATE] 1:00 PM, R3 was noted with aggressive behavior, screaming at other residents coming her way. Very impatient and argumentative. g) [DATE] Monthly charting - " Has 1 episode of physical abuse." h) [DATE] 5:30 PM, R3 was noted coming out of her room and following R7. R3 stated " She is tearing the bed apart, I pulled her out of the room." i) [DATE] 11:30 am, R3 screams and yells at anyone coming her way. R3 also pushes other residents who sits on her table. j) [DATE] Monthly Nursing Summary Charting - Gets upset easily when provoked. k) [DATE] Monthly Nursing Summary Charting - indicated that R3 easily gets upset. l) [DATE] 1:00 PM, R3 will scream at other residents getting on her way. m) [DATE] Monthly Nursing Summary Charting - indicated that R3 gets easily upset when provoked. R3's Social Service Notes dated [DATE] and [DATE] also indicated that R3 becomes very angry and physically aggressive, if someone intrudes upon her space. It also said that staff must continue to monitor other residents and R3, for intrusion upon R3's personal space. According to E8 ( morning CNA ) on [DATE] at 2:00 PM, R3 does not want anyone going in her room. E8 said that she saw R3 yell at R2 before, for going in R3's room. E8 added that R2 is confused and she goes to R3's room. Similarly, E5 also said during [DATE] interview at 2:15 PM, that she also saw R2 wander to R3's room once or twice, approximately a month prior to [DATE]. E5 said that R3 gets agitated when she sees another resident inside her room. Per R2's nurses notes, on [DATE], at 6:40 AM, R3 came out of room 165 yelling " Get her out of my room. She is back again." This nurses note indicated that R2 was found on the floor on her back, with the back of her head resting against the corner of a closet. Additionally, it was observed that R2 had a cut on the right upper lip and there is a lot of blood. 911 was called and R2 was sent to the hospital. According to E5 during [DATE] interview at 2:15 PM, when E6 ( nurse ) and she got to R3's room, R2 was lying on her back on the floor, with her head against the corner of a drawer. E5 said R2 was bleeding. E5 continued that R3 said that R2 pushed her ( R3), so she pushed R2 back. According to E3 on [DATE], R2 had a cut across her lip, her face was swollen, and there was blood all over. During [DATE] interview at 2:15 PM, E3 said that she was assigned to R2 on night shift on [DATE] until 7 AM of [DATE]. E3 said that after R2 woke up early, she took R2 to the dining room at around 6:15 AM. E3 said that E4 was passing medications to the residents during this time. E3 said this was the last time she saw R2, prior to being found bleeding inside R3's room. E4 said during [DATE] interview at 1:16 PM, that she last saw R2 in the dining room when she was passing meds, 15 to 20 minutes before R2 was found in R3's room. E7 ( morning shift CNA ) said on [DATE] interview at 12:09 PM, that although she came in at 6:00 AM, she showered a resident and did not see R2 prior to the incident. Per E5 on [DATE] at 2:15 PM, although she came to work at 6:30 AM, she did not see R2 until R3 yelled to get R2 out of her room. On [DATE] at 4:30 PM, E6 ( morning shift nurse ) also said that she did not see R2 when she came in, until she rushed to go inside R3's room and found R2 lying bloody on the floor. Although R2 has a care plan to identify her wandering behavior, there was really no intervention in place to prevent her from going to the room of R3, who is aggressive, territorial, and physically and verbally towards other residents who wanders to her room. Per E3 during [DATE] interview at 2:15 PM, if the staff sees R2 wandering, they redirect R2. Other than that, there was no further intervention in place, to provide R2 or other wandering residents like R6 and R7 with supervision to prevent them from going to R3's room. E3 said that she is not aware, that R3 can be physically aggressive to other residents who enters her room. E3 said no one told her that R3 had pushed out other residents out of her room in the past. Similarly, E8, E9, and E6 also verbalized during above individual interviews, that they are not aware of R3's behavior of being physically aggressive towards residents who wander inside her room. According to E3 on [DATE], if she knew R3 can be physically aggressive to other residents, E3 would have stayed with R2 that morning of [DATE], until E4 is done with her work. Added to the lack of supervision for the wandering residents, the facility also failed to ensure that R3 who was pushed R2 and caused her injuries, was immediately supervised and closely monitored after the altercation with R2 on [DATE]. Although R3 said that she pushed R2 after R2 pushed her first, R2's lip laceration and swollen face is in front, and is not consistent with her falling backwards and landing on her back and the back of her head. During [DATE] interview with E5 at 2:15 PM, E5 said that while the staff are taking care of R2, R3 walked to the dining room and sat with about 3 residents. E5 said that there was no staff with her during this time. Similarly, E7 also said on [DATE] at 12:09 PM, that while the nurses were treating R2 in R3's room, E7 did not see R3 in the hallway or the dining room. E7 said she went to the dining room for about 15 minutes, then went to the rooms. After that, E7 said that we went back to the dining room for assist residents with breakfast. E7 said that at this time, she saw R3 sitting with 2 female residents ( one of which is R5), and was joined by male resident later in the small dining room. E7 said there were no staff in the small dining room to watch R3, because this dining room is for independent residents who do not need staff during meal time. E7 said that if she is standing by the TV in the dining room, she could see R3 in the small dining room. E7 said she fed the other residents by the refrigerator, which has no visual access to the small dining room and R3. R3's nurses notes showed that on [DATE] at 2 PM, R3 continued to be physically aggressive to other residents. R3 grabbed another resident's hand and tried to twist it. On [DATE] at 10 PM, R3 was noted yelling at other residents. On [DATE], R3's nurses notes indicated that R3 is easily agitated and territorial. The facility took the following steps to remove the Immediate Jeopardy : 1) Immediately, R2 was sent to the hospital via 911 on [DATE]. R2 returned to the facility on [DATE], but was sent back to the hospital the next day on [DATE]. The facility was notified that R2 expired at the hospital on [DATE]. 2) R3 was sent out to the hospital on [DATE] and was returned to the facility on [DATE] at 2:50 AM. R3 was provided with a sitter on the night shift of [DATE] to ensure 1:1 monitoring and was sent out again to the hospital on [DATE] at 11:40 AM for further evaluation. R3 was reassessed upon returned to facility and a care plan ( CP ) meeting with family was held on [DATE]. R3 was moved to a room closer to the nurses station and main area and placed in a private room. A removable barrier that includes a STOP sign was placed on R3's door entrance to deter wandering residents from going inside R3's room. R3 was also referred to a psychiatrist that resulted to adjustment of her medications. These interventions were reviewed with unit staff and CP was reviewed by MDS nurse, DON, ADON, Social Worker, Administrator, CP coordinator, and unit nurse. no issues had occurred since implementation of these interventions. 3) The facility's IDT ( MDS nurse, DON, Activity staff, Social Service and Administrator assessed all of the Dementia Unit's residents to identify those with wandering, physically and verbally aggressive, and territorial behaviors on [DATE] and was reviewed again on [DATE] and [DATE] by the above IDT. 4) The facility developed a new assessment protocol for risk assessment for residents on the Dementia Unit. This assessment reviews risk and identifies residents who may develop behavior issues. This was done and completed on [DATE] by Social Worker. Upon admission or readmission, the resident will be assessed using this new protocol. This assessment will be reviewed at least quarterly along with MDS or in case of new or declining behaviors. 5) The facility's CP team ( Social Worker, DON, ADON, Care Plan Coordinator ) has updated and revised each care plan of residents identified as having above behavior issues and has reviewed these updates with staff on [DATE]. This will be ongoing on a quarterly basis to coincide with each resident's care plan schedule. Upon identification of new or declining behaviors, the care plans of the residents will be updated and modified by MDS nurse, Social Service staff, nurses, and Activity staff. This was started in [DATE] and will be an ongoing process. 6) During morning report, the behaviors on the unit will be included and Dementia Unit were trained on [DATE]. This was implemented on [DATE]. 7) A Dementia training was done on [DATE] for all staff by Social Worker. A Dementia training was also done for the Dementia Unit staff by the DON and ADON on wandering behaviors of the residents. Another training on behavior interventions and supervision was done on [DATE] by Administrator and ADON and was completed on [DATE]. All staff on leave or those newly hired will be required to take the training prior to returning or starting to work starting [DATE]. 8) The Unit manager will review starting [DATE], all the new admission and readmission charts within 72 hrs of admission to assess for compliance with risk assessment and development of interim care plan for the identified behaviors. This will be completed in [DATE]. The unit manager will also audit 10 charts a month for the risk assessment completion and corresponding behavioral care plan and present this as part of QA to the QA committee next QA meeting on [DATE]. 9 ) The medical record staff will audit all Dementia Unit staff for compliance with education and training for behaviors. This will be done and completed on [DATE] and will continue quarterly as part of QA process. 10 ) The Social Worker, DON, ADON, and Nursing Supervisor will conduct observational audits on the unit 6x per month to cover each shift starting [DATE]. This will include observations of staff interventions while dealing with residents with behavioral issues. The result of this audit will be presented to QA starting [DATE]. 11) The QA coordinator will hold an emergency QA meeting on [DATE] to cover the above plan and implementation.