Every finding on record at Citadel of Sterling,The

Based on observation, interview, and record review the facility failed to ensure a resident had catheter change orders, current physician recommendations for catheter changes were followed, and catheter tubing was kept off the floor for 2 of 3 residents (R2 & R3) reviewed for catheters in the sample of 6.The findings include:1. On 8/30/26 at 11:54 AM, R3 was sitting in a wheelchair in the dining room. R3 had an indwelling urinary catheter with the tubing on the floor. The urine in the tubing was cloudy yellow with thick sediment present. V5 Assistant Director of Nursing - ADON walked by the dining room and was asked to look at the resident. V5 stated she could see already that his tubing was on the floor and it should not be. V5 stated catheter tubing should not be on the floor for infection control reasons. V5 confirmed that he had cloudy urine with sediment present.On 8/30/26 at 1:29 PM, V2 stated catheter tubing should not be touching the floor for infection control reasons.The Physician Orders for R3 did not show any orders for when his catheter was to be changed.On 8/30/26 at 3:30 PM, V2 Director of Nursing - DON stated were supposed to have orders for when their catheters are to be changed. V2 stated R3 had his suprapubic catheter placed on 3/28/26 and all it said was that he had a suprapubic catheter, to check the catheter/drainage bag for problems and to notify the provider when it needs to be replaced. V2 stated she could not find any documentation showing any orders for when it was to be changed. V2 did not have any information on R3's medical record at the facility that showed when his catheter was last changed. V2 had to obtain the information from electronic medical records outside of the facility.The Face Sheet dated 8/30/26 for R3 showed diagnoses including Parkinson's, bronchitis, COPD, type 2 DM acute kidney failure, epilepsy, atherosclerotic heart disease, chronic kidney disease, anemia, hydronephrosis, benign prostatic hypertrophy, dementia, depression, hypertension, atrial fibrillation, hypercholesterolemia, falls, and hyperlipidemia.The Care Plan dated 7/26/26 for R3 showed R3 requires use of an indwelling urinary catheter related to obstructing kidney stone with hydronephrosis. Change catheter as ordered.The Progress Note dated 7/9/26 showed R3 was started on an antibiotic for a urinary tract infection.The facility's Urinary Catheter Care policy (8/2022) showed the purpose of this procedure was to prevent catheter associated complications, including urinary tract infections. Be sure the catheter tubing or drainage bag are kept off the floor.2. On 8/30/26 at 9:42 AM, R2 was sitting in a wheelchair by the nurse's station. R2 had an indwelling urinary catheter in place with the tubing visible. There was pale cloudy yellow present in the tubing and white sediment present.On 8/30/26 at 2:50 PM, V2 DON was shown the note on 8/16/26 from the Nurse Practitioner for R2 that showed she stated he was to have monthly catheter changes. V2 stated the NP probably forgot to give them and order to do that. V2 was unable to locate in the facility's chart for R2 any documentation in the last three months that his catheter had been changed.The Physician Orders dated 8/30/26 for R2 showed the last order entered for catheter changes was dated 6/21/26 and said to change as needed. The orders did not reflect the providers note dated 8/16/26 for R2 and monthly catheter changes.The 30 day Follow Up Note for R2 from the nurse practitioner showed a history of urinary retention and indwelling catheter with a history of urinary tract infections and prior sepsis. Chronic catheter for retention; monthly changes and as needed for obstruction/sediment.The Care Plan dated R2 is at risk for infections related to his catheter due to diagnoses of retention, benign prostatic hypertrophy, obstructive and reflux uropathy. Change catheter as ordered/needed.The facility's Urinary Catheter Care policy (8/2022) showed the purpose of this procedure was to prevent catheter associated complications, including urinary tract infections. The policy did not show anything related to following physician orders related to catheter changes.

Based on observation, interview, and record review the facility failed to ensure safe transfers were provided for residents for 2 of 4 residents (R1 & R4) reviewed for safety and supervision in the sample of 6.The findings include:1. The Incident Report dated 8/19/26 for R1 showed: This nurse was notified by R1 that she had bruising to the left big toe that had developed the night before. Assessed the area to the skin and noted bruising to the left big toe with slight redness. R1 stated during transportation the night before her left big toe hit the wall. The interdisciplinary team met to discuss R1's bruising to the left great toe likely due to bumping during a transfer.On 8/30/26 at 11:04 AM V4 CNA stated R1 had a bruise to her toe and said that somebody rammed it into something. R1 said it happened last week but would not say who did it. R1 can't move her wheelchair herself. R1 is pushed in her chair wherever she wants to go by them.On 8/30/26 at 11:09 AM V3 Certified Nursing Assistant - CNA stated R1 can't walk but she can bear weight so the stand lift was used for transfers for her. V3 stated most of the time they push R1 in her wheelchair. V3 stated R1 was alert, oriented, and knew what's going on. V3 stated R1 told V3 that someone hit her toe when she was being transferred.On 8/30/26 at 11:14 AM, V2 Director of Nursing - DON stated, R1 told her that her toe was bumped on a wall. V2 stated staff were interviewed and they did not know how it happened. V2 stated the investigation of the incident was documented in risk management.The Minimum Data Set (MDS) dated [DATE] for R1 showed she was dependent for transfers.The Care Plan dated 8/18/26 for R1 showed she is at risk for impaired skin integrity due to decreased/impaired mobility. Monitor positioning of R1's feet while assisting with transfers to reduce risk of bumping her toes.The Face Sheet dated 8/30/26 for R1 showed medical diagnoses including spinal stenosis, type 2 diabetes mellitus, resistant to multiple antimicrobial drugs, infection and inflammatory reaction due to urethral catheter, morbid obesity, anxiety disorder, muscle weakness, heart failure, osteoarthritis, atherosclerotic heart disease, hypertension, paroxysmal atrial fibrillation, sciatica, goiter, hyperlipidemia, obstructive sleep apnea, cataract, temporomandibular joint disorder, spinal stenosis, low back pain, neuromuscular dysfunction of the bladder, and retention of urine.The facility's Using a Mechanical Lifting Machine policy showed the purpose of this procedure to establish the general principles of safe lifting using mechanical lifting device. Mechanical lifts may be used for tasks that require transferring a resident from bed to chair; lateral transfers; lifting limbs - avoid bumping; toileting or bathing; or repositioning. 2. On 8/30/26 at 12:01 PM, - V8 Certified Nursing Assistant - CNA and V9 CNA were at R4's bedside to transfer her from her bed to a wheelchair using a full mechanical lift. R4 was lying in bed with a mechanical lift sling under her. V8 and V9 attached the sling to the lift. V9 controlled the lift while V8 guided the resident. R4's right leg hit the mechanical lift a couple of times during the transfer. V10 CNA came into the room during the transfer. R4 was lowered into her wheelchair, and her right foot hit the lift and V10 moved R4's foot. The CNAs were asked what they could have done differently during the transfer and V8 stated they could have had more control over R4's legs so they didn't knock into the machine. V9 and V10 nodded in agreement with what V8 said.On 8/30/26 at 1:29 PM, V2 DON stated staff are to provide safe transfers for residents and avoid bumping their extremities during transfers. Staff should try to be as gentle as possible during transfers.The Face Sheet dated 8/30/26 for R4 showed diagnoses including right side hemiplegia/hemiparesis, metabolic encephalopathy, acute respiratory failure with hypoxia, pneumonia, moderate protein calorie malnutrition, non-st elevated myocardial infarction, cardiogenic shock, type 2 diabetes mellitus, chronic obstructive pulmonary disease, cerebral infarction, dysphagia, cognitive communication deficit, dysarthria and anarthria, congestive heart failure, acute kidney failure, chronic kidney disease, melena, hyperlipidemia, hypercholesterolemia, intracardiac thrombosis, anemia, and hypertension.The MDS dated [DATE] for R4 showed she was dependent for transfers.The facility's Using a Mechanical Lifting Machine policy showed the purpose of this procedure is to establish the general principles of safe lifting using mechanical lifting device. Mechanical lifts may be used for tasks that require transferring a resident from bed to chair; lateral transfers; lifting limbs - avoid bumping; toileting or bathing; or repositioning

Based on interview and record review, the facility failed to follow the state Power of Attorney Act when a facility nurse became a resident's Health Care Power of Attorney and the nurse was allowed to continue care for the resident as her nurse at the facility. The facility also allowed a director (Assistant Director of Nursing) to witness the signing of the resident's Health Care Power of Attorney form. This applies to 1 of 3 residents (R1) reviewed for Power of Attorney (POA) in the sample of 5.The findings include:R1's Face Sheet showed diagnoses to including, but not limited to, anxiety, falls, heart failure, and schizophrenia. On 8/18/26 at 10:15 AM, R1 stated she did not know who her doctor was, what month it was, and she did not know the year. R1 stated, a power of attorney (POA), .takes care of stuff if you die. R1 said, Don't know who I would have make those decisions if I got sick, I never really thought about it.R1's Minimum Data Set (MDS) from 6/20/25 (MDS near the time her POA was signed) and 7/1/26 both showed moderate cognitive impairment with a Brief Interview for Mental Status score of 8 and 9 out of 15 respectively.R1's Power of Attorney for Health Care, provided by the facility, showed V4 (Licensed Practical Nurse-LPN) was named as R1's Power of Attorney. The form was signed by R1 and witnessed by V3 (Assistant Director of Nursing-ADON) on 7/31/25.R1's Progress Note from 7/31/25 at 5:26 PM showed V4 was communicating with R1's physician in an official caregiver capacity. (Prior to signing POA paperwork.)R1's progress note showed V4 performed a physical assessment of R1 on 8/2/25 at 2:17 AM. (Post POA paperwork signing.)On 8/18/26 at 12:04 PM, V8 (Social Services) stated she has worked at the facility for several years. V8 stated R1 was a resident of the facility in July 2025 and R1 was discharged home on 8/2/25. V8 stated, following R1's discharge, R1 fell at home and fractured her leg, which resulted in her readmission and current admission to the facility on 9/15/25. V8 stated, following R1's readmission, V4 continued in her role as R1's Power of Attorney as well as a facility nurse; however, R1 was able to make her own healthcare decisions. V8 stated V4 would have been R1's direct care nurse on occasion following R1's readmission on [DATE]. V8 stated she was not aware, until recently, that the Power of Attorney was not allowed to be a direct care provider. V8 stated V4 should not have been allowed to be R1's direct care nurse once V4 allowed herself to be R1's Power of Attorney. V8 said the reason for this separation is due to a conflict of interest. V8 stated, V4 withdrew her Power of Attorney, in writing, on 7/31/26.R1's Progress Notes showed the last documented note which was authored by V4 was on 5/4/26 stating, Patient has a reddened area under her left breast. [R1's Physician] notified. Treatment orders initiated.R1's 7/13/26 Social Service note from 8:45 AM, showed V4 was R1's POA and attended R1's care plan meeting. On 8/18/26 at 12:28 PM, V3 (Assistant Director of Nursing) stated she would no longer witness Power of Attorney signing and she was not aware, at the time of signing R1's POA, that she was not allowed to witness. V3 stated she was not aware on 7/31/25 that V4 was not allowed to be both R1's POA and her direct care nurse. V3 stated she now understands the reason for this separation is, it would be difficult to think clearly when the person providing care is also the person making the healthcare decisions and that person may not have the resident's best interests in mind. On 8/18/26 at 9:40 AM, V4 was called and a message was left. V4 did not return the phone call prior to exiting on 8/18/26 at 4:00 PM.On 8/18/26 at 11:23 AM, V2 (Director of Nursing) stated she messaged V4 to return this surveyor's phone call.On 8/18/26 at 2:15 PM, V2 (Director of Nursing) stated the facility did not have a policy regarding Power of Attorney. The Illinois Power of Attorney Act (755 ILCS 45/) showed, (755 ILCS 45/4-4) (from Ch. 110 1/2, par. 804-4). (d) Health care provider, health care professional, or provider means the attending physician and any other person administering healthcare to the patient at the time of reference who is licensed, certified, or otherwise authorized or permitted by law to administer health care in the ordinary course of business or the practice of a profession, including any person employed by or acting for any such authorized person. (755 ILCS 45/4-5) (from Ch. 110 1/2, par. 804-5) Sec. 4-5. Limitations on health care agencies. Neither the attending physician nor any other healthcare provider or health care professional may act as agent under a health care agency; however, a person who is not administering health care to the patient may act as health care agent for the patient even though the person is a physician or otherwise licensed, certified, authorized, or permitted by law to administer health care in the ordinary course of business or the practice of a profession. (Source: P.A. 98-1113, eff. 1-1-15.). The POA act stated regarding witnessing, (755 ILCS 45/4-5.1) Sec. 4-5.1. Limitations on who may witness healthcare agencies. (a) Every health care agency shall bear the signature of a witness to the signing of the agency. No witness may be under [AGE] years of age. None of the following licensed professionals providing services to the principal may serve as a witness to the signing of a health care agency:. (2) an owner, operator.The prohibition on the operator of a healthcare facility from serving as a witness shall extend to directors and executive officers of an operator that is a corporate entity.

Based on observation, interview, record review the facility failed to ensure the 3-compartment sink was at the correct sanitization level, failed to serve cold food below 41 degrees Fahrenheit and failed to wash hands and change gloves after touching contaminated surfaces for all 87 residents reviewed for dietary services residing in the facility.The findings include: The CMS Form 671 dated 4/28/26 shows a resident census of 87.On 4/28/26 at 9:46 AM, V5 [NAME] tested the 3-compartment sink which had dishes in every compartment. V5 dipped the test strip into the disinfectant compartment, and the strip showed orange in color indicating 100 PPM. V5 said the strip should be green, closer to 200 PPM. On 4/28/26 at 9:54 AM, V5 was dumping the leftover pan of eggs, with gloved hands, V5 removed the lid of the garbage can and began dumping the eggs. The garbage can started rolling away from V5 and V6 grabbed the garbage can to stop it from moving with her hands. V6 had a glove on her right hand only. V5, when finished dumping the food, put the lid back on the trash can and put the pan in the 3-compartment sink. V5 then walked over to the stove and without removing her gloves or hand washing, flipped the grilled cheese sandwiches that were cooking. V6 went to the dishwasher area and without removing one glove and washing her hands, proceeded to put away clean cups from the clean tray that had come out of the dishwasher. On 4/28/26 at 10:05 AM, V4 Dietary Manager said the sanitizing level of the 3-compartment sink should be between 200-300 ppm. On 4/28/26 at 11:16 AM, the coleslaw for the noon meal was in a compartment of the steam table. V5 checked the temperature of the coleslaw which read 58.6 degrees Fahrenheit. V5 said this should be colder, it was made at 9:00 AM and it had been in the fridge. V5 served the coleslaw for the noon meal.On 4/28/26 at 12:25 PM, V4 Dietary Manager said cold foods should be served at 41 degrees Fahrenheit or below. V4 said staff should remove their gloves and wash their hands when touching any non-food product, including the garbage can.The facility's Three Compartment Sink Policy dated 9/22/23 shows Add the appropriate amount of sanitizer to the water according to the manufacturer's guidelines: Quaternary Ammonium: 200 PPM.The facility's Tray Services Policy dated 10/25/23 shows Cold foods are maintained at 41 degrees Fahrenheit.The facility's Handwashing Policy dated 9/21/23 shows Employees will use proper hand washing techniques to prevent the spread of infection, cross contamination, and germs.

Based on observation, interview, and record review the facility failed to ensure pureed food was palatable for 11 of 11 residents (R10, R18, R19, R20, R42, R50, R54, R55, R56, R83, R89) reviewed for puree in the sample of 40. The findings include: The facility's Daily Spreadsheet for Week 2 Tuesday Lunch puree shows ground BBQ pork, soft roasted rosemary potatoes, soft cooked hot vegetables.On 4/28/26 at 10:30 AM, V5 [NAME] measured portions of carrots for the noon meal and poured them into the puree machine. V5 added hot water to the machine and pureed the carrots. V5 then poured the carrots into a metal serving pan and placed them into the steam table. V5 said for the roasted rosemary potatoes she used instant mashed potatoes which were already on the steam table. On 4/28/26 at 12:09 PM, this surveyor was served a sample of the pureed noon meal. The pureed carrots appeared watery on the plate and were without flavor. The mashed potatoes were thick and pasty and had very little flavor. On 4/28/26 at 12:25 PM, V4 Dietary Manager tasted the carrots and the mashed potatoes. V4 said the carrots are watery and bland and the potatoes are thick and bland. V4 said V5 has trouble pureeing the rosemary potatoes so she uses mashed potatoes, but she should at least use the rosemary seasoning to give it flavor. V4 said V5 should use the cooking water from the carrots for flavor, not hot water.The Puree Roasted [NAME] Potatoes without Skin Recipe shows prepare potatoes following instructions in original recipe, except peel potatoes and be sure to use chopped rosemary. Place prepared skinless potatoes in food processor and blend until smooth, adding small amounts of hot broth, as needed, until desire consistency is reached. Roasted [NAME] Potatoes recipe shows Melt margarine and combine with oil, chopped garlic, chopped rosemary, and all remaining ingredients (garlic powder, paprika, salt, black pepper).The Puree Cooked Hot Vegetable Recipe shows Place prepared vegetables in food processor. Blend, adding cooking liquid as needed, until smooth and correct consistency is reached.The facility's Menu and Nutritional Adequacy Policy dated 10/2/23 shows Standardized recipes for menu items will be used to help ensure consistent quality, portion size, and cost control. All recipes will be followed as written.

Based on observation, interview, and record review the facility failed to ensure safety measures were in place for a resident at risk for falling for 1 of 7 residents (R21) reviewed for safety in the sample of 40. The findings include:R21's face sheet dated 4/30/26 showed diagnoses to include, but not limited to morbid obesity, insomnia, urinary frequency, fatigue, vascular dementia, cataracts, osteoarthritis, reduced mobility, and need for assistance with personal cares. R21's facility assessment dated [DATE] showed she had moderate cognitive impairment and was dependent on staff for toilet hygiene, personal hygiene, bed mobility, and transfers. R21's Care Plan reviewed 11/13/25 showed R21 was at risk for falls due to weakness, pain, osteoarthritis, and transient ischemic attack (TIA). R21's Fall Risk Evaluation dated 2/11/26 showed she had a high fall risk. This document showed she had intermittent confusion and was incontinent. On 4/28/26 at 10:14 AM, R21 was in bed with the head of bed elevated. R21's bed was not in the lowest position. R21's bed was up in the air, and the bottom of the bed was even with the bottom of the surveyor's rib cage (3.5 feet off to from the floor). R21 had her breakfast tray on the overbed table. R21 said she didn't know why her bed was up so high. R21 said the bed had been up in that position for a while. R21 wasn't sure which girl (staff member) was in her room last, but stated, They couldn't figure out how to get the bed down. R21 asked the surveyor if she knew how to lower the bed because it was too high. The surveyor pushed the bed lower button on the side rail, and it didn't move. At 10:17 AM, the surveyor asked V11 (Registered Nurse) to come to R21's room. V11 said R21's bed was too high and should be lowered for safety. V11 went to R21's side rail and attempted to move the bed down. The bed didn't move. V11 moved to the other side, pressed the bed down button and the bed did not move. V11 looked under the bed to see if something was unplugged. R21 stated, They (previous staff) couldn't get me down either. V11 said she would notify maintenance to check R21's bed. V11 walked to the foot of the bed, pressed a button, returned to the bed controls and was able to move R21's bed to the lowest position. V11 said someone pushed the lock button on the foot of the bed, that's why it wasn't moving. (R21 was not able to use the buttons on the bed and was not able to raise the bed herself. It was left in the high position by facility staff.) V11 said R21's bed should be lowered to the point that if she sat up on the side of the bed her feet would be on the floor. The surveyor asked V11 if R21's feet would have been able to reach the floor at the height of the bed initially. V11 replied, Of course not. V11 said the purpose of proper bed height was to decrease the risk of falls and reduce the risk of serious injury if a fall occurred. V11 said R21 had some dementia and can be confused at times. V11 said R21 was able to make her needs known and was a fall risk. On 4/30/26 at 10:25 AM, V2 (Director of Nursing - DON) said general safety precautions for all residents in bed include bed in low position, wheels locked, call light in reach, and side rail up if indicated for use. V2 said general safety precautions are important to reduce the risk of falling and prevent serious injury if a fall occurred. The surveyor explained R21's bed was level with the bottom of her rib cage (3.5 feet from the floor). V2 said there is no reason the bed should be left that high. V2 said if one of the facility staff shouldn't have left R21's bed up high without addressing the issue. V2 said there are residents that may play with the bed buttons. The surveyor explained that the bed control buttons were locked on R21's bed and had to be unlocked by V11 (RN) to move the bed down. V2 said R21 was alert, but forgetful. V2 said R21 doesn't normally try to get up but she was a fall risk. V2 said R21 was able to make her needs known. The facility's Safety and Supervision of Residents Policy dated 7/2017 showed, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview, and record review the facility failed to ensure consistent dementia care was provided for 1 of 1 resident (R41) reviewed for dementia care in the sample of 23. This failure resulted in R41 exhibiting repetitive, uncontrolled combative behaviors, medication not being provided as ordered and a femur fracture. The findings include: R41's face sheet showed she was admitted to the facility 7/7/20 with diagnoses to include dementia without behavioral disturbance, Type 2 Diabetes, diverticulosis of intestine, dysphagia, major depressive disorder, seizures, and age-related osteoporosis. R41's facility assessment dated [DATE] showed she has severe cognitive impairment and is dependent on staff for all cares. R41's care plan initiated 4/8/25 showed, I have decreased mobility skills, I need staff assistance to roll to side in bed. I can become combative towards staff and resist when staff are assisting me . R41's care plan initiated 7/7/20 with most recent revision 5/10/25 showed, I am at risk for impaired skin integrity due to dementia, hypertension, seizures, diabetes, and the use of aspirin/Plavix which increase my risk to bruising and bleeding. I am resistive to care, often becoming combative with staff during assistance, and may grab or push at the lift device . A right leg immobilizer is used as needed for comfort Interventions: . 2/5/25 Immobilizer to left leg as needed for comfort. Inspect my skin around brace when in use 2/8/23 side table moved to prevent bumping . Transfers/Bed Mobility: Use caution when assisting me with transfers and bed mobility to prevent striking my arms, legs, or hands Use caution when assisting with turning/positioning. Ensure pillow or similar is placed between bed/nightstand to prevent bumping When giving care/positioning be aware of surroundings to prevent bumping . R41's care plan initiated 3/31/22 showed, I am at risk for alteration in comfort, secondary to pain related to cancer and depression . 8/8/24 Pain and swelling right knee X-RAY negative and ruled out DVT (deep vein thrombosis), Spring Right Knee: Ace Wrap until healed; 8/12/24 Pain, swelling left knee and swelling and bruise left foot kicking resisting care: X-Ray left knee and left foot . 12/2 bruising right knee . R41's care plan initiated 8/14/24 showed, I have decreased mobility skills, I need a Hoyer and 2 assist to transfer due to swelling and bruised left foot and resisting transfer with stand lift R41's 8/8/24 Incident Report showed, 11:20 PM . During lay down CNA staff informed this nurse that resident had swollen right knee. Upon assessment it is noted that resident's right knee was edematous and visibly larger than the left knee. No bruising or redness noted. Resident unable to extend her leg without screaming in pain. Painful upon touch as well order to send to [acute care hospital] for further evaluation to rule out DVT (deep vein thrombosis) . R41's 8/8/24 Acute Care Hospital documentation showed, . Chief Complaint: Patient arrives via EMS left sided leg swelling after a fall when she hit her knee. Physician wanted to rule out DVT. History: dementia, uses lift to transfer R41's 8/9/24 Progress Note entered at 12:48 AM showed, Resident returned from [acute care hospital] . diagnosis of right knee sprain. Tylenol was given in the ER for pain, no changes to current medications. Left knee X-ray performed, negative for acute abnormalities. Right lower extremity venous ultrasound, negative for acute abnormalities. Resident returned with ace wrap to right knee with instructions to continue using ace wrap until pain and swelling are gone or as instructed by primary care provider . resident continues to have complaints of pain upon movement. It is also noted that resident appears to have new bruising as well as swelling to left foot. Resident does not complain of pain in the left foot . R41's August 2024 eMAR (electronic Medication Administration Record) showed she received Tylenol on 8/9/24 at 9:00 AM for knee pain. R41's 8/9/24 Progress Note entered at 1:48 PM showed, Right knee continues to have edema, painful when moved. Up for church and lunch. No signs of distress when leg not moving. R41's 8/9/24 Progress Note entered at 6:58 PM showed, Monitoring resident due to right knee sprain. During care or ROM (range of motion)/repositioning resident complains pain to right knee . Right knee also remain edematous, ace wrap placed on residents right knee for swelling and pain. Complains when placed ace wrap on . R41's eMAR administration note entered 8/10/24 at 4:58 AM showed scheduled Ativan not given due to not being delivered from pharmacy. R41's 8/10/24 Progress note entered at 12:28 PM showed, Patient showing no signs of pain this shift due to right knee sprain. Feet and ankles remain bruised at this time. R41's August 2024 eMAR showed an order for Ativan 1 mg to be given twice daily. R41's eMAR showed she did not receive her Ativan from 8/10/24 through 8/14/24 due to it not being available. R41 missed 9 doses of Ativan between 8/10/24 and 8/14/24. This same eMAR showed an order for olanzapine (antipsychotic medication) 2.5 mg to be given daily. The eMAR showed R41 did not receive 10 of her 12 scheduled doses of antipsychotic medication from 8/19/24 through 8/30/24. The eMAR showed administration of the olanzapine 8/22/24 and 8/27/22. R41's eMAR administration notes dated 8/19/24,8/20/24, 8/21/24, 8/23/24, 8/24/24, 8/25/24, 8/26/24, 8/28/24, 8/29/24, and 8/30/24 all showed olanzapine was not available for administration. R41's care plan initiated 6/6/22 showed, I have a behavior problem of becoming verbally and physically aggressive during my care related to my dementia and lacking ability to comprehend what staff are trying to do for me. I will become combative and yelling/cursing, hitting, kicking . These behaviors end once care is completed . Interventions: . Administer medications as ordered. Monitor/document for side effects and effectiveness . R41's 10/7/24 Pharmacy Consultation Report related to use of Ativan showed to continue Ativan related to behaviors and anxiety with reductions likely leading to decompensation. R41's 8/12/24 Incident Report showed, . Resident observed to have swelling to left knee and swelling and bruise to left foot. Pain on touching foot and knee . May have occurred when transferring with stand lift last pm (evening) as she resists care. Bedrest this am (morning) and elevated to reduce swelling Awaiting return call to obtain order for portable X-ray of left foot and knee. Resists care, stand lift has been used for transfers . R41's 12/2/24 Progress Note entered at 9:12 AM showed, This nurse called to patient's room and witnessed a bruise to the right knee. Patient denies pain and no discomfort noted at this time. Patient has had issues and X-rays to this knee prior to today. ROM (range of motion) checked and no deficits .X-rays ordered. R41's 12/2/24 Incident Report showed, . This nurse called to patients room and witnessed a bruise to the right knee Often combative during cares, swinging and kicking at staff. Often kick legs over bed rails . 12/3/24 Often combative with care. Place pillow between legs and rail with care. V23's LPN (Licensed Practical Nurse) statement dated 12/2/24 showed, . asked by [V24 CNA (Certified Nursing Assistant)] to assess, combative with repositioning. Knee has been swollen since sprain . [V24] reports resident often bumps legs on rails when attempting to kick at staff. Based on interview, likely bumped right femur on rail causing a fracture from direct impact to rail. R41's acute care hospital documents dated 12/2/24 showed, . Chief Complaint; Patient here via emergency medical services for right leg pain and swelling . Patient is a resident of [the facility] and has had many falls recently. Patient has a history of advanced dementia. Patient presents to the emergency department via ambulance for evaluation and treatment of a broken leg. Patient has advanced dementia is non-ambulatory . Per nursing home she was diagnosed with a fracture of her leg and was sent here for evaluation and treatment. there is no documentation of the patient falling any time recently. She was seen here in August of this year after a fall and had an ultrasound and imaging of her left leg that was unremarkable. Caregivers report the patient has right leg trauma today . patient does not answer any questions and just screams incoherently at me when I attempt to examine her . X-ray femur 2 views Right . Clinical History: right femur trauma . Findings: . Comminuted and moderately displaced fracture of the distal shaft of the femur Patient has deformity above the right knee but no evidence of cellulitis infection . Imaging demonstrates a subacute healing fracture of the distal femoral shaft. I discussed these findings with [orthopedic physician]. He reviewed the images personally and stated the fracture was old of several months and there was nothing to be done acutely since the patient is non-ambulatory. He recommended a knee immobilizer and follow up in the office on an outpatient basis . Patient is discharged in stable condition with a knee immobilizer . Wear knee immobilizer for pain control and comfort . On 5/21/25 at 2:32 PM, V25 LPN (Licensed Practical Nurse) said, [R41] has been pretty good lately and very compliant with medications . She will occasionally yell out during cares but as far as I know she hasn't been combative for quite a while. They don't know how the fracture happened actually. They were trying to rule out spontaneous, but I don't know if they ever did that because she hadn't had a fall. She is very osteoporotic. On 5/22/25 at 7:55 AM, V24 CNA (Certified Nursing Assistant) said, About 6 months ago I went in to get [R41] up for the day and when I took the blankets off of her to get her washed up and dressed, I saw her knee. It was kind of a round bruise maybe the size of a 50 cent piece a couple inches above her knee. I believe it was purple. She wasn't complaining of pain really. If I remember right that was about the time that she was being combative with us during care and she was kicking a lot. I just thought maybe she might have kicked the bed rail at some point. I have seen her hit the bed rail before. She also would hit and kick at us which would in turn cause her to kick the bedrail. When she is combative, depending on the situation, if it is morning, a lot of times we will just cover her back up and let her relax for a few minutes, go get another aide and see if she would be better with them. Reapproach, sometimes they just need a few minutes to fully wake up. On 5/22/25 at 9:54 AM, V21 (Memory Care Unit Director/Registered Nurse) said, [R41] went out to the hospital and was X-rayed in August and they did not find anything. Her complaints started with the opposite leg than the one that fractured in December. In August there was no fracture, then later we noticed she was having swelling and pain with the other but there was no known injury, falls, or anything that would have caused the fracture. We don't know what happened that caused the fracture. Ortho couldn't really tell us other than they said it was not new. They did some adjustments with her medications too. There are several that go in and try to talk to her and redirect her. She likes baby dolls and stuffed animals that usually comforts her. On 5/22/25 at 10:03 AM, V22 said, [R41's] behaviors depend on the day. When they are providing incontinence care and showers she will resist and gets combative. She was combative during care and the CNAs came and got me and reported it and we saw the bruise. I think it happened during that care. She really flails and it is not a soft flail. We have tried to reapproach and give her a few minutes. Sometimes that works and sometimes it doesn't. She really likes to be left alone and not messed with . We aren't sure what happened back in August, [the hospital] said it was a sprain. We think it's from being combative then too. She has a habit of kicking and swinging. That is why we have the rails padded .When we are missing a medication . we can call pharmacy and pull form the convenience supply . Ativan is in the convenience supply. The problem sometimes with Ativan and those medications, if the person doesn't have a valid script we can't pull form the box. It might be getting low, so we fax the script to the doctor. If the doctor doesn't sign and get it back to pharmacy, we can't pull it .Usually if its serious we call the doctor. call the pharmacy, fax the pharmacy, wait for them to call us back . On 5/22/25 at 10:27 AM, V23 (Restorative Nurse) said she was aware of [R41's] fracture. I knew she didn't have any recent falls which is why I probably wasn't involved in an investigation. If there is a fall, I'm involved in that investigation . On 5/22/25 at 1:32 PM, V3 ADON (Assistant Director of Nursing) said R41 has a history of combative behaviors. V3 said when staff try to provide care R41 will hit, kick, spit, and bite. V3 said sometimes R41 will be sitting out in the dining room and if you say hello to her, she will start screaming for no reason. V3 said R41 is very anxious. V3 compared the medication administration notes with the eMAR (electronic medication administration record) and said the Ativan and Olanzapine was not available. V3 said depending on what the medication is that they don't have they could check the convenience supply box to see if its available. If they don't have a valid prescription, she expects the nurses to notify the doctor and document in the progress notes that they were doing that and when the medication will come. V3 said she would expect nursing staff to ensure medications are available and if they are not available, she would expect them to contact the pharmacy and the physician to find out why. V3 said R41 takes Ativan for anxiety and Olanzapine for her diagnoses of major depressive disorder. V3 said she was not part of the investigation into R41's injuries but she can see her getting fractures from resisting care because she is very resistive. The facility's policy reviewed July 2018 showed, Dementia . Treatment/Management . For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life . The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements Monitoring and Follow Up . The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician . the IDT will adjust interventions and the overall plan depending on the individuals responses to those interventions, progression of dementia, development of acute medical conditions or complications . The facility's policy revised March 2019 showed, Behavioral Assessment, Intervention, and Monitoring . The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care . Management: 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. safety strategies will be implemented immediately if necessary to protect the resident and others from harm Monitoring . Interventions will be adjusted based on the impact on behavior and other symptoms including any adverse consequences related to treatment .

Based on observation, interview and record review the facility failed to provide proper fitting plate lids to keep foods hot during transport and failed to ensure palatable food temperatures. These failures have the potential to affect all 96 residents who receive meals in the facility. Findings include: Facility Room Roster (provided on 5/20/25) indicates 96 residents/occupied beds. On 5/20/25 at 9:50 AM, R17 stated she always eats in her room and often her food is cold when they deliver her tray. V27, Family stated R17's food often is cold and does not like to eat it that way. V27 stated he was thinking of getting a microwave for R17's room. On 5/20/25 at 10:15 AM, R12 stated her breakfast is often cold. On 5/21/25 at 10:00 AM (during the group meeting) R9 stated her vegetables are often cold. On 5/21/25 from approximately 11:50 AM to 11:55 AM the C-Hall meal tray cart was filled with lunch meal trays for distribution to C-Hall residents eating in their rooms. A test tray was also placed into the C-Hall cart prior to leaving the kitchen. The plated foods placed on the C-Hall cart were covered with lids - some were clear lids that completely fit over the entire plate and foods, and some were smaller black lids that did not entirely cover the plated foods. For the C-Hall cart only, V8, Dietary Manager covered the plated foods with a layer of plastic wrap prior to the small black lids being placed. Neither V8 nor any of the other dietary staff placed plastic wrap on the other room tray carts that had already left the kitchen for distribution. At that time, V8 acknowledged the black lids did not fit properly over the plated foods and plastic wrap would help keep the food protected and warm. The test tray was one of the plates of food that was covered in plastic wrap and a black lid. V8 did not give an explanation for the other carts leaving the kitchen without being plastic wrapped. On 5/21/25 at 11:55 AM the C-Hall meal cart left the kitchen for distribution to residents eating in their rooms. At that time, V8 stated that the C-Hall meal cart is the last cart that has room tray distribution. Upon arrival to C-Hall the resident meal trays were distributed to the appropriate residents. At 12:10 PM, after the last resident tray was passed, the test tray was unwrapped and V8 took temperatures of the following food items and liquids: Breaded Pork Cutlet - 124 degrees (F) Mixed vegetables - 153 degrees (F) Herbed [NAME] - 117 degrees (F) Applesauce 55 degrees (F) Fruit punch - 54 degrees (F) At that time, V8 acknowledged that the temperatures would be even lower if the tray had not been wrapped in plastic prior to being loaded onto the tray cart. Facility Policy/Food and Sanitation: Tray Service dated 10/25/23 documents: Employees will use measures to ensure the sanitation and safety of food provision on the tray line, transportation of meals, and tray delivery. Cold foods are maintained at 41 degrees (F/Fahrenheit). All food that is transported from the kitchen to other areas for service will be handled in a safe manner, covered to prevent contamination, and in closed food carts. Hot foods will be at least 120-135 degrees (F) and cold foods at 40-45 degrees (F) at the time of service for palatability.

Based on observation, interview and record review the facility failed to ensure a clean/sanitary dishwashing area, failed to ensure safe refrigerator temperatures for cold foods, failed to provide serving trays in a presentable and safe manner, and failed to ensure dietary staff wore hair coverings properly. These failures have the potential to affect all 95 residents who receive meals in the facility. Findings include: Facility Room Roster (provided on 5/20/25) indicates 96 residents/occupied beds. 1) On 5/20/25 at 9:15 AM noted a black, thick substance along the lower wall where the kitchen dish machine counter met the wall in a partially enclosed small area with poor ventilation and which is frequently wet due to the garbage disposal scraping sink and steam from the dish washer machine. The black substance was thickest at the juncture of the wall and counter and appeared to be growing up the wall on three sides. At that time V8, Dietary Manager stated that he had cleaned and painted where the black areas are when he first took over as Dietary Manager (in October 2024), but the black substance came back. V8 stated the black areas are unsightly and should not be there. 2) On 5/20/25 at 9:20 AM Two door reach in refrigerator had cheese, butter and eggs stored on the left side. The eggs, located underneath the blocks of butter had a yellowish, thick substance adhered to the top of the eggs. At that time, V8, Dietary Manger confirmed with V10, [NAME] that the substance on top of the eggs was butter. V8 perforated three of the blocks of butter with the hand-held thermometer which read as 45 degrees (F/Fahrenheit), 46 degrees (F) and 48 degrees (F). V8 stated the Reach in cooler refrigerator temps are supposed to be 41 or less. On 5/20/25 at 11:50 AM V8, Dietary Manager stated he threw away all the food in the two-door refrigerator and contacted a repair service to look at the refrigerator. Job Invoice dated 5/20/25 indicates Reach in cooler running warm. Cooler has Evap that is froze up so will return 5/21/25 to repair to allow for defrost time. Job Invoice dated 5/21/25 indicates Added refrigerant to low system on two-door reach in cooler. Unit now running as it should. 3) On 5/21/25 at 10 AM during a group meeting, R9 and R38 stated that some of the meal trays are old and worn and stated they do have some new trays, but they don't use them all the time. R9 stated she received a tray the other day that was like a [NAME] totter. R38 stated he had a wobbly tray. On 5/20/25 and 5/21/25 during lunch meal preparation and meal service, meal trays were noted to be excessively worn, with cracked, chipped and jagged areas along the edges and corners of the trays. On 5/21/25 V8 acknowledged the trays were old, unsightly should be replaced and were potentially hazardous. 4) V9, V11, V12 and V28, Dietary Aides and V10, [NAME] working in kitchen on 5/20/25 and 5/21/25 did not have hairnets that completely contained or covered all of their hair. All had at least 50% of their hair uncovered or hanging from the front, sides and/or back. On 5/21/25 at 1:15 PM V8 stated that he has and will continue to instruct dietary staff on keeping all hair covered while in the kitchen and has considered providing a different type of covering to staff that may assist in compliance. Facility Policy/Food Safety and Sanitation: Storage of Refrigerated/Frozen Foods dated 4/26/24 documents: Refrigerator and freezer food items will be properly stored to keep foods safe and preserve flavor, nutritive value, and appearance. Refrigerated foods are maintained at or below 41 degrees (F/Fahrenheit). Refrigerator doors will be opened as little as possible to prevent fluctuation of storage temperature. Facility Policy/Food Safety and Sanitation: General Preparation and Cooking Practices dated 9/18/23 documents: Hairnets or caps and beard guards are used in the preparation of food. The food service employee will ensure workstations, cutting boards and utensils are clean and sanitized. Dishes and silverware are free from chips, cracks, or stains and have glaze intact. Facility Policy/Food Safety and Sanitation: Tray Service dated 10/25/23 documents: Foods will be tasted and presented on trays that are inviting to ensure quality of the food.

Based on observation, interview, and record review the facility failed to ensure a residents catheter tubing was secure, free of entrapment, and drainage bag was off the floor for 1 of 4 residents (R28) reviewed for catheters in the sample of 23. The findings include: On 5/20/25 at 9:15 AM, R28 was sitting in a wheelchair with his indwelling urinary catheter tubing wrapped around and between his leg. When R28 moved in his wheelchair the tubing would get caught behind his left heel. On 5/21/25 at 3:50 PM, V1 (Administrator) stated R28 was very particular about his catheter. V2 Director of Nursing (DON) stated R28 has a clip on the catheter tubing; but it does come undone at times because he is active. V2 stated they could use a strap at the top and bottom of the tubing to keep it in place. On 5/22/25 at 9:25 AM, R28 was sitting on the toilet with his drainage bag on the floor. R28 had a secure lock device on his thigh that was peeling of and was in place to secure the catheter tubing. R28 stated the secure lock device comes off when he takes a shower. R28 stated his catheter was pulled out and hurt bad. On 5/22/25 at 9:27 AM, V3 Assistant Director of Nursing (ADON)/ Wound Nurse stated R28 has a history of erosion to his penis. V3 stated it is a good idea to have the secure lock device in place for the catheter, so they don't pull. On 5/22/25 at 11:08 AM, V3 stated the catheter drainage bag should not be on the floor for infection control. The Face Sheet dated 5/22/25 for R28 showed diagnoses including retention of urine, personal history of malignant neoplasm of prostate, hypertension, gout, hyperlipidemia, benign prostatic hyperplasia, obstructive and reflux neuropathy, polyneuropathy, sleep apnea, chronic kidney disease, generalized edema, obesity, chronic obstructive pulmonary disease, and osteoarthritis. The Physician Orders dated 5/22/25 for R28 showed, catheter care every shift for catheter use. Catheter drainage bag: change as needed for catheter; label and date. Change every night shift every 2 weeks on Sunday. Check to ensure catheter is secure at all times with secure device due to penile erosion every shift. The Care Plan dated 4/12/25 for R28 showed he is at risk for impaired skin integrity due to having a catheter in place, a history of redness, soreness, and swelling in the penis and groin area. Provide catheter care per orders. Provide peri care every shift and as needed/requested. The Care Plan dated 4/12/25 for R28 stated he is at risk for infections related to hi catheter and due to a diagnoses of retention, benign prostatic hypertrophy, obstructive and reflux uropathy. R28 have a history of prostate cancer. R28 has a history of urinary tract infections. Position the catheter bag and tubing below the level of the bladder. Keep tubing and bag off the floor. The Physician's Note dated 4/16/25 at 6:41 PM showed he is alert and oriented x 4 (person, time, place, and situation). The Skin/Wound Note dated 12/26/24 at 11:12 AM showed, seen by wound doctor for wound care related to open area to the right side of penis, catheter induced. R28 has a history of penile erosion. Secure lock device in place and switched to the left side. The facility's Catheter Care Policy (July 2020) showed, Infection Control - Be sure the catheter tubing and drainage bag are kept off the floor. Changing Catheters - Ensure that catheter remains secured with a leg strap to reduce friction and movement at the insertion site.

Based on interview and record review, the facility failed to provide privacy for a resident (R39) during dressing. This applies to 1 of 1 residents reviewed for privacy in the sample of 23. The findings include: R39's electronic face sheet printed on 5/22/25 showed R39 has diagnoses including but not limited to type 2 diabetes, adjustment disorder, wedge compression fracture of unspecified lumbar vertebra, major depressive disorder, and anxiety disorder. R39's facility assessment dated [DATE] showed R39 has no cognitive impairment. R39's care plan dated 4/18/25 showed, I have depression related to my admission to the facility and current health condition that has caused me great pain and mobility limitation. I have diagnosis of Major Depressive Disorder and General Anxiety. I am having difficulty with my roommate and another female peer. I am a very private person and have asked for my roommate to not talk about me or discuss with others about my medications. I have declined to move to another room because I like my room and feel that moving is not the right solution for me. It is very stressful and tearful. On 5/21/25 at 9:23AM, R39 stated, I was getting ready for the day and had no clothes on. I had both of my privacy curtains pulled and one of the aides asked if she could come through and get to the sink. I asked her to give me a minute. She then asked again if she could come through and I told her to please wait until I was dressed but she came through anyway. This happened right after one of the male aides made a negative comment about my thighs being big, so I was already feeling down about my body. This has happened twice now, and I don't feel like my privacy is respected. We are trying to work out a solution for this, but it should've never happened in the first place. I did talk to (V14-Social Services) about it so we are working on it. I don't want any of the staff seeing me naked unless absolutely necessary. I can get myself dressed and do most things on my own so there is no reason why they should be coming in my space when I specifically ask them to please wait. I realize they need to get to parts of the room to help my roommate but hopefully we can work something out. (R39 was tearful throughout entire conversation and verbalized she was afraid to tell surveyor because she didn't want to get in trouble). On 5/21/25 at 2:40PM, V14 (Social Services) stated, (R39) will say she has concerns, you address it, she'll say she doesn't want staff in her room, then she will come back and say she never said that. Most recently, her concern was when her curtain was pulled and one of the aides came through the curtain. I was told that the staff member didn't go through the curtain but opened the bathroom door which was nothing to do with (R39) and did not expose her or invade her privacy. Staff will tell (R39) they need to come through to get water for her roommate. They aren't looking at her they are trying to take care of her roommate who needs care, and they need to get to the sink for the washcloths. They can still go through the curtain and just not look at (R39), that wouldn't be a big deal. I think we have found a solution, but I really don't think her privacy was invaded at all, I think she just thought it was. (R39's care plan was reviewed and showed no documentation of R39 making false allegations). The facility's policy titled, Confidentiality of Information and Personal Privacy with a review date of October 2017 showed, Our facility will protect and safeguard resident confidentiality and personal privacy .2. The facility will strive to protect the resident's privacy regarding his or her .d. personal care The facility's policy titled, Quality of Life-Dignity with a review date of February 2020 showed, 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 .1. Residents are treated with dignity and respect at all times .4. Residents' private space and property are respected at all times. 5. Staff are expected to knock and request permission before entering residents' rooms .10. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on interview and record review, the facility failed to protect 2 residents (R28, R49) from physical abuse, and failed to provide sufficient protection to prevent resident to resident abuse. These failures apply to 2 of 3 residents reviewed for resident-to-resident abuse in the sample of 23. The findings include: R53's electronic face sheet printed on 5/22/25 showed R53 has diagnoses including but not limited to dementia without behaviors, psychosis, and anxiety disorder. R53's facility assessment dated [DATE] showed R53 has severe cognitive impairment. R53's care plan revised 4/9/25 showed, I have behaviors that could increase the potential for abuse or neglect. These identified behaviors are verbal/physical aggressive behavior, dementia/impaired cognition, poor judgement . R49's facility assessment dated [DATE] showed R49 has no cognitive impairment. R28's facility assessment dated [DATE] showed R28 has mild cognitive impairment with no disorganized thought processes. On 5/21/25 at 11:44AM, R49 stated, I was out front and (R28) started coming up from the dining room and suddenly (R53) started slapping on us. She has dementia and doesn't realize what she's doing so I just backed up and said no, no, no but she caught up to me and hit me on the back. I don't know what precipitated it she just does that sometimes. She was slapping on my arm. They asked me if I was ok and I was, but it just shocked me because nothing really happened except, I told (R53) not to take the blanket off another lady's lap because the lady was cold, and it wasn't (R53's) blanket. On 5/21/25 at 11:52AM, V16 (Licensed Practical Nurse) stated, I was working on the opposite unit, and I heard (R53) yell out and when I looked down the hall, (R53) and (R28) were in the hallway and she yelled, You better not even think about it! I saw her slapping his arm and yelled out for her to stop. (V17-Registered Nurse) was at the nurse's station but she did not intervene. I'm not sure if she would have heard it or not but I heard it all the way down the hall, and they were doing this pretty much right next to the nurse's station. On 5/22/25 at 9:08AM, V17 RN (Registered Nurse) stated, I was sitting at the nurse's station and (R53) was in the front lobby. Something caused her to become agitated. she grabbed the blanket off another resident's lap and (R49) was up there and I heard him say No (R53), you can't hit and I went up there and she was going after him and he was wheeling himself backwards. When she caught up to him, she smacked him on the back. I took (R53) by me at the nurse's station and gave her the stuffed cats she always holds. She left the nurse's station then and went towards the dining room area. That's when (V16) brought (R53) back to the nurse's station and said she hit (R28) twice on the arm. On 5/22/25 at 9:25AM, R28 stated, (R53) and I were going down the main hallway and she always tries to go ahead of me, so I tried to go around her. She yelled 'You better not even think about it!' and she slapped me on my right arm. It hurt the rest of the day, so she had some force behind it. I didn't say anything to her or do anything to her, she just hit me for no reason. On 5/22/25 at 05/22/25 11:51AM, V1 (Administrator) stated, (V17) called me and said (R53) tried to take a blanket from another resident. (R49) tried to get between them because he is close with (R53) and then (R53) came into contact with his arm and (R28) was going by and she shouted something and as (R28) was going by she swatted towards him in the back. When a resident makes contact with a resident, I would expect staff to assess all residents for any injury. I came to the facility right away to make sure everyone was ok. These assessments would be documented in the resident's chart so I'm not sure why nothing was documented. We checked on everyone and they were all ok and (R53) was sent out for a psychiatric evaluation and her psychotropic medication was increased. It's impossible for us to predict when something like this will occur. I did not substantiate abuse because (R53) has Dementia and she didn't know what she was doing. Neither (R28) or (R49) told me that they had been hit by (R53) when I interviewed them. I asked them both if they had any concerns and they told me No. I'm not sure what else I could've done to get the full story from them. (R28 and R49's medical records showed no documentation of assessments following the incident nor were there any nurse's notes regarding the incident with R53) The facility's policy titled, Abuse and Neglect-Clinical Protocol with a review date of June 2023 showed, 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .4. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . The facility's policy titled, Abuse Prevention Program dated 10-2022 showed, This (facility) affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment .Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking .

Based on observation, interview, and record review the facility failed to do quarterly assessments for a resident with a lap buddy restraint in place for 1 of 1 resident (R60) reviewed for restraints in the sample of 23. The findings include: R60's face sheet showed she was admitted to the facility 9/30/22 with diagnoses to include Alzheimer's Disease with late onset, Type 2 Diabetes, repeated falls, obstructive and reflux uropathy, major depressive disorder, anxiety disorder, and history of falling. R60's facility assessment dated [DATE] showed she is severely cognitively impaired, is dependent upon staff for all cares, and has a history of falls. R60's Physical Device/Physical Reminder Informed Consent showed, [R60] . Method of Physical Restraint/Physical Device is needed: to help prevent falls from wheelchair as a reminder . Verbal consent obtained 6/17/24 R60's care plan initiated 10/11/22 showed, I had an actual fall and continue to be at risk due to left femur fracture, Alzheimer's Disease, hypertension, history of falls, incontinence . I will attempt to self-transfer and self-ambulate. I prefer to use the lap buddy when I explore the unit . Interventions: 6/14/24: Will trial lap buddy while up. Please remove it during meals, activities, and upon my request. I like to keep my lap buddy when I explore the unit . 6/17/24: Place lap buddy on my wheelchair when up out of bed to enhance safe wheelchair mobility and release every 2 hours and PRN (as needed) with supervision . R60's June 2024 Physician Order Sheet showed, 6/17/24 - May use lap buddy on wheelchair when out of bed to enhance safe wheelchair . R60's record showed no evidence of an initial restraint assessment or quarterly restraint assessments from June 2024 through May 2025. On 5/20/25 at 10:27 AM, R60 was in the dining room listening to an activity with a lap buddy in place. On 5/21/25 at 9:55 AM, V20 CNA (Certified Nursing Assistant) and V24 CNA were toileting R60 using the stand lift. R60 required multiple reminders in addition to staff having eventually to physically place her hands on the stand lift bar due to her cognitive deficits. On 5/22/25 at 11:18 AM, V23 said R60 has only had the lap buddy since her last fall or at least within 2025. On 5/22/25 at 11:37 AM, V23 (Restorative Nurse) said there are no restraint assessments for R60. The facility's policy reviewed April 2017 showed, Use of Restraints . Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls when the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented .

Based on observation, interview and record review the facility failed to provide appropriate indications for use of antipsychotic medications for three residents with diagnosis of Dementia (R3, R17, R78) of six residents reviewed for unnecessary medications in the sample of 23. Findings include: 1) Current Physician Orders indicate R3 is [AGE] years old with diagnoses that include Anxiety Disorder, Recurrent Major Depressive Disorder, Unspecified Dementia with Agitation and Delusional Disorder. Summary Report indicates R3 has orders for Seroquel (antipsychotic) 200mg (milligrams) twice daily related to Delusional Disorder dated 2/24/25. R3's Psychotropic Medication Consents are as follows: 2/1/25 - Seroquel 100mg twice daily for Depression - signed by R3. 2/7/25 - Seroquel 200mg at bedtime for anxiety/restlessness - verbal consent from R3. 2/24/25 - Seroquel 200mg twice daily for Depression - verbal consent from R3. On 5/21/25 at 10:15 am R3 was in her sitting on her bed. R3 stated she knows that she is on Seroquel thinks for depression. R3 denies hallucinations/hearing voices or seeing things that aren't there, does have interrupted sleep at night. R3 was able to answer questions appropriately. R3 did not appear to be responding to any internal stimuli or seem to be experiencing hallucinations or delusions. On 5/21/25 at 10:25am V29, CNA (Certified Nurse Assistant) stated she is very familiar with R3 and stated that R3 has had no behaviors lately; has had bad days before mostly upset with family - threatening to throw things in her room. V29 stated she has never seen R3 hallucinate or have delusional behaviors. Pharmacy Consultation report dated 1/6/25 recommends to decrease R3's Seroquel to 50mg every morning and 100mg at bedtime. Recommendation was declined by physician due to Likely decompensation. Current Care Plan indicates R3 has Mood/Depression and receives Seroquel 200mg twice daily, Cymbalta (antidepressant) 60mg at bedtime, Celexa (antidepressant) 20mg every morning and Ativan (antianxiety) 1mg three times daily. Areas of impact include feeling down, depressed, trouble falling or staying asleep, feeling tired or having little energy, poor appetite at times, feeling bad about myself, trouble concentrating on things and increased anxiety. Initiated 12/20/23; revised 3/20/25. Care Plan does not designate which target behaviors/interventions are for which medications. On 5/22/25 at 2:10pm V14, SSD (Social Service Director) stated they recognize R3 is on a very high dose of Seroquel for her age but seems to be tolerating it well. V14 stated they are unsure if R3 has a history of bipolar disorder and stated R3 has had episodes of being religiously preoccupied, however it has not been persistent. 2) Current Physician order Report Summary indicates R17 is [AGE] years old, was admitted to the facility 10/21/22 and has diagnoses that include Anxiety Disorder, Unspecified Hallucinations, Recurrent Major Depressive Disorder and Vascular Dementia with Behavioral Disturbance. Report Summary indicates R17 has orders for Seroquel (antipsychotic) 25mg (milligrams) every evening related to Hallucinations (Order date 6/26/24). Psychotropic Medication Consent dated 3/23/24 indicates, There should be a diagnosis to support each medication listed, if no medical diagnosis supports it, give reason for use. Consent indicates Seroquel 25mg every evening for Insomnia was consented to by V27, Family for R17 on 3/23/24. Psychotropic Medication Consent dated 6/13/24 indicates, There should be a diagnosis to support each medication listed, if no medical diagnosis supports it, give reason for use. Consent indicates R17 receives the following medications: Clonazepam (antianxiety), Zoloft (antidepressant), Seroquel 12.5mg every evening(antipsychotic) and Venlafaxine (antidepressant). None of the listed medications have a diagnosis or reason for use on the consent. Consent Summary of Behavior indicates, Depression. Consent is signed by V27, R17's POA (Power of Attorney). Pharmacy Consultation Reports dated 1/6/25 and 4/2/25 recommendations were to decrease R17's Seroquel to 12.5mg every evening. Physician's response on both pharmacy report recommendations were declined and R17's Seroquel remained at 25mg every evening. On 5/22/25 at 9:30am V27 stated R17's Seroquel was first ordered when R17 was initially admitted because She didn't want to be here and kept trying to get out of bed. V27 acknowledged R17 was having trouble adjusting and had a couple of falls. V27 stated, The hope was that the medication (Seroquel) would help settle (R17) down and keep her from getting out of bed and falling. V27 stated they did increase the dose when R17 was having difficulty sleeping. V27 stated a nurse told me About a month ago they wanted to decrease the dose and he agreed it would be ok. V27 stated, I thought it had been decreased and she was getting half a pill now. During the conversation with R17 and V27, R17 was appropriate in her responses with moderate memory impairments. There was no evidence of R17 responding to internal stimuli or experiencing hallucinations or delusions. Behavior Monitoring and Interventions for March, April, May 2025 indicate R17 had No Behaviors. Current Care Plan (date initiated 10/26/22; revised 3/9/25) indicates R17 is a potential elopement risk related to disorientation to place and impaired safety awareness. Care Plan indicates R17 has a history of active hallucinations and delusional thoughts believing that she is leaving the facility. Care Plan also indicates R17 has limitations with her mobility and is a fall risk. Care Plan indicates R17 receives Seroquel 25mg in the evening for hallucinations No behaviors noted. On 5/22/25 at 2Pm V14, SSD (Social Service Director) stated she is responsible for Psychotropic Medication Management. V14 stated that R17 is not followed by psychiatry services. V14 stated that R17's Seroquel was discontinued 12/1/22 by Psychiatric Services at that time because they did not find justification for its use. V14 stated that R27 called R17's primary physician and had the Seroquel re-ordered and that's when psychiatric services stated they would no longer follow R17. 3) Current Physician Order Summary Report indicates R78 is [AGE] years old and has diagnoses that include Mood Disorder, Vascular Dementia with Behavioral Disturbance. Report indicates R78 receives Seroquel 25mg three times daily related to Unspecified Mood Disorder (date initiated 4/19/25). Psychotropic Medication Consent dated 7/17/24 indicates consent for Seroquel 25mg three times daily was signed on that date for resists care, wanders, exit seeks, restlessness, agitation, anger, looking for wife and insomnia. Pharmacy Consultation Report dated 11/6/24, 12/4/25, 1/6/25 and 3/5/25 recommends attempting a Gradual Dose Reduction due to numerous falls to 25mg daily of R78's Seroquel. Physician declined the recommendations due to Doing well on regimen. Current Care Plan indicates R78 has potential for behavioral disturbances of verbal/physical aggression, agitation and anxiety related to Vascular Dementia. Care Plan indicates R78 receives Seroquel (antipsychotic), Trazodone (antidepressant), Zoloft (antidepressant) and Ativan (antianxiety). Care Plan does not designate which target behaviors/interventions are for which medications. On 5/22/25 at 2:15pm V14 SSD stated R78 is seen by the VA (Veterans Administration) and acknowledged Seroquel has not changed or decreased R78's behaviors. The Facility Policy/Antipsychotic Medication Use dated 2016 documents: Antipsychotic medications may be considered for residents with Dementia but only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and review. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: The behavioral symptoms present a danger to the resident or others; AND: The symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity; or Behavioral interventions have been attempted and included in the plan of care, except in an emergency. Antipsychotic medications will not be used if the only symptoms are one or more of the following: wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia, inattention or indifference to surroundings, sadness or crying alone that is not related to depression or other psychiatric disorders, fidgeting, nervousness, uncooperativeness. Facility Policy/Behavioral Assessment, Intervention and Monitoring dated 2016 documents: When medications are prescribed for behavioral symptoms, documentation will include: Specific target behaviors and expected outcomes.

Based on observation, interview, and record review the facility failed to apply tube dressings as ordered by a physician for 2 of 5 residents (R94 and R48) reviewed for physician orders in the sample of 23. The findings include: 1. R94's face sheet showed he was admitted to the facility 4/3/25 with diagnoses to include chronic obstructive pulmonary disease, arthritis due to other bacteria, hypertension, cardiomegaly, gout due to renal impairment, and congestive heart failure. R94's facility assessment showed he has severe cognitive impairment and requires substantial to maximum assist for all cares. R94's care plan initiated 4/5/25 showed, I am at risk for impaired skin integrity related to advanced age, Chronic obstructive pulmonary disease (COPD), Decreased mobility, Dementia, Incontinence, aortic stenosis, aortic valve insufficiency, congestive heart failure with the use of tubular support bandages for edema to legs . Interventions: EDEMA: Assist me with applying Tubigrips (compression tubular support bandages) to my legs every morning and removing at bedtime. Use caution when applying/removing; do not tug or pull. Make sure there are no wrinkles/rolled. Inspect my skin with each application/removal . R94's May 2025 Physician Order Sheet showed an order dated 4/24/25 for Compression: (tubular support bandages) to ble (bilateral lower extremities) on in the am (morning) off at hs (bedtime) one time a day for swelling. R94's eTAR showed on 5/1/25, 5/2/25, 5/4/25, 5/6/25, 5/8/25, 5/15/25, 5/16/25, and 5/20/25 showed the evening nurse scheduled to remove the tubular support bandages documented None on when this nurse went to remove. The same eTAR documented the (tubular support bandages) applied everyday with the exception of 5/11/25. On 5/20/25 at 12:09 PM, R94 was in his room lying in bed. R94 did not have his compression support dressings on. On 5/21/25 at 9:38 AM, R94 was lying in bed. R94 did not have his compression support dressings on. On 5/22/25 at 10:24 AM, R94 was lying in bed. R94 did not have his compression support dressings on. On 5/22/25 at 10:15 AM, V22 LPN (Licensed Practical Nurse) said R94 should currently have his support dressings on. V22 said R94 wears the support dressings for bilateral lower extremity edema. On 5/22/25 at 10:24 AM, V21 (Memory Care Director) said R94 is not wearing his support dressings at this time. V21 said R94 did have the dressings before but she does not know where they are now. V21 checked R94's room and did not find the support dressings. On 5/22/25 at 10:35 AM, V20 CNA (Certified Nursing Assistant) said, I have never known him to have (tubular support bandages). I've never seen any in his room and I've never put any on him. This is the first time I have heard anything about him having any. On 5/22/25 at 1:23 PM, V3 ADON (Assistant Director of Nursing) said, I just went down there (to memory care unit) and printed out a list for them of the people who have orders for (tubular support bandages). I have a supply here and down in the therapy room. We have all the equipment. I put them down where they are accessible. The nurse should tell the CNAs who has (tubular support bandages) and they should be reading the care plans. I expect the nurse to confirm the (tubular support bandages) are on before they document that they are on. If a nurse goes in to remove the (tubular support bandages) and they are not on I would expect them should find out why they aren't there. I checked his room, and he didn't have any. The facility's policy revised July 2016 showed, Physician Orders.; Policy Statement: Physician orders will be consistent with principles of safe and effective order writing Physician orders will be carried out in a timely manner . 20042 2. On 5/20/25 at 12:45 PM, R48 was sitting in a wheelchair in the doorway of her room. R48 had a dressing and tubular bandage to her left leg. R48's right leg did not have a tubular bandage in place. R48 had a low cut sock and shoes on her right lower extremity. On 5/21/25 at 9:01 AM, R48 was sitting in a wheelchair out in the hall. R48 had a blue dress on. R48 had a dressing and tubular dressing in place to her left lower extremity. R48 had a tubular dressing in place to her right lower extremity. R48 stated she has lymphedema. R48 stated her left leg has the dressing in place and a tubular dressing because that leg is weeping. R48 stated she didn't have the tubular dressing to her right leg yesterday because it was wet and hanging up to dry. R48 stated the tubular dressing was hanging up because two nights ago (Monday night) the Certified Nursing Assistant (CNA) left them in a bucket of water. The CNA forgot to wash it and hang it up to dry overnight. R48 stated she is supposed to have the tubular dressing in place every day. R48 stated she can't wear the other wraps to her legs because they cut into her legs. On 5/21/25 at 9:11 AM, V7 Licensed Practical Nurse (LPN) stated R48 should have tubular dressings and they should be on. V7 stated they might have been wet. They should be washed at night and hung up to dry. V7 stated the third shift nurse puts them on the resident. On 5/21/25 at 9:15 AM, V3 Assistant Director of Nursing (ADON)/Wound Nurse stated the tubular dressings are supposed to be put on in the morning and removed at night for both legs. The Certified Nursing Assistant (CNA) is supposed to rinse the tubular dressing when they are removed at night and hang them up at night, so they dry. V3 stated the tubular dressings are to help with R48's lymphedema. The Face Sheet dated 5/21/25 for R48 showed diagnoses including chronic kidney disease, morbid obesity, shortness of breath, cardiac murmur, iron deficiency anemia, hypoglycemia, generalized anxiety disorder, hemorrhoids, lymphedema, major depressive disorder, vitamin D deficiency, venous insufficiency, chronic venous hypertension with ulcer of bilateral lower extremity, acute kidney failure, other specified dermatitis, and varicose veins of lower extremity. The Physician Orders for R48 showed an order dated 5/6/25 for tubular dressings to the right and left leg; on in the morning and off at bedtime.; one time a day related to lymphedema (on) and in the evening related to lymphedema (off). The Electronic Medication Administration Note for R48 dated 5/20/25 at 5:28 AM showed the tubular dressing was not applied because they were hanging to dry due to being just washed. The Minimum Data Set (MDS) dated [DATE] for R48 showed no cognitive impairment. The facility Physician Orders policy (July 2016) showed, physician orders will be carried out in a timely manner.

Based on observation, interview, and record review the facility failed to ensure a preventative device was inflated to provide offloading for 1 of 5 residents (R29) reviewed for pressure injuries in the sample of 23. The findings include: On 5/20/25 at 9:21 AM, R29 was laying on her right side in bed while V5 Wound Care Physician was evaluating a pressure injury to her left thigh and coccyx. V3 Assistant Director of Nursing (ADON)/ Wound Nurse was at bedside and stated R29 leans to her side in her wheelchair and that caused her thigh wound. V3 stated the air inflated cushion was put in her chair because of this. V5 stated the left thigh wound was healed and reopened two weeks ago. V5 stated R29 had a couple wounds to her buttocks that have healed, and now she has the new area to her coccyx. The air inflated cushion in R29's wheelchair was deflated on the left side, and in the middle near the back of the cushion. The right side was fully inflated. V3 pushed on the cushion, and it easily flattened out on the left side and in the back. It remained partially sunken when pressure was not applied. V3 stated the cushion needed more air. R29 stated the cushion has been flat for two weeks. R29 told V3 that the cushion gets so flat that she tries to sit further back in her chair. On 5/20/25 at 9:37 AM, V7 Licensed Practical Nurse (LPN) looked in the computer and stated R29 had an order placed 3/25/25 for the inflated cushion to her wheelchair and the cushion was put in place that day. V7 stated the third shift nurse is supposed to check for proper inflation of the cushion and signed out in the computer that it was being checked. On 5/21/25 at 1:40 PM, V3 stated on 5/20/25 after R29's wound care was provided and there was a concern with the offloading cushion she had the resident sit in her chair and checked the cushion. V3 stated the resident complained that the cushion was flat. Air was put into the cushion and then R29 was checked again according to manufacturer's recommendations for proper inflation. R29 stated it did not feel right so the cushion was switched to another inflated cushion. The Face Sheet dated 5/21/25 for R29 showed diagnoses including chronic obstructive pulmonary disease, abnormal posture, hypokalemia, chronic kidney disease, unspecified abdominal pain, edema, anemia, erythema intertrigo, osteoarthritis, hypothyroidism, hypertension, and hyperlipidemia. The Wound Evaluation & Management Summary dated 5/20/25 for R29 showed a stage III pressure injury to her coccyx and a non-pressure wound of the left posterior thigh with an etiology of trauma/injury. The physicians recommendations included off-loading wounds. The Skin/Wound Note dated 5/6/25 at 12:16 PM for R29 showed, continues to be followed by the Wound Care Physician at the facility regarding the right buttock wound. Inflated cushion to wheelchair. Left posterior thigh, new orders for skin treatment paste. The Care Plan dated 4/2/25 for R29 was revised on 5/20/25 and showed she is at risk for impaired skin integrity and prefers to spend her leisure time in her wheelchair. Inflated cushion to wheelchair while in use. Check function/proper inflation. Nurse to check inflated cushion for proper inflation using the hand check method. The Physician Orders for R29 showed an order dated 3/25/25 that said the nurse is to check inflated cushion for proper inflation. The Minimum Data Set (MDS) dated [DATE] for R29 showed no cognitive impairment. The facility Pressure ulcers/Skin Breakdown - Clinical Protocol (4/2018) showed the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition, the nurse shall describe and document/report the following: current treatments including support surfaces. 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.

Based on observation, interview, and record review the facility failed to ensure the safety of a resident dependent on staff for cares for 1 of 7 residents (R60) reviewed for safety in the sample of 23. The findings include: R60's face sheet showed she was admitted to the facility 9/30/22 with diagnoses to include Alzheimer's Disease with late onset, Type 2 Diabetes, repeated falls, obstructive and reflux uropathy, major depressive disorder, anxiety disorder, and history of falling. R60's facility assessment dated [DATE] showed she is severely cognitively impaired, is dependent upon staff for all cares, and has a history of falls. R60's care plan initiated 10/11/2022 showed, I had an actual fall and continue to be at risk due to left femur fracture, Alzheimer's Disease, hypertension, history of falls, and incontinence. I will self-transfer and self-ambulate . 4/3/25: observed on floor near doorway . Interventions: . 4/3/25 Staff to remain in bathroom with resident . R60's care plan initiated 10/1/2024 showed, I have decreased mobility skills. I will transfer with stand lift and assist of 2 . R60's Incident Report dated 4/3/25 showed, This nurse is sitting at nurses station and heard a thud and heard a resident yell help, help, help. This nurse ran quickly to the situation and noted the resident laying on the floor on her back in front of her bedroom door (door is wide open) with her pants around her ankles. CNA is with resident when this nurse arrived to room . On 5/23/25 at 9:05 AM, V26 CNA (Certified Nursing Assistant) said, . Depending on how [R60] is for the day she will try to stand up out of her chair, so we do have to sometimes do one on one with her, so she doesn't stand up and fall obviously. I was a new hire at the time she fell for me, I had only been down on [R60's] wing 2 or 3 times, I was working with 2 other aides that didn't know that wing very well either, I had never transferred [R60] before and it was either during dinner or around dinner. She tried to stand up and I could see she was soiled so I needed to take her to the bathroom. I took her to her room. I think I accidentally looked at the resident's care information who was a 1 assist. I got [R60] onto the toilet and reached out for some wash clothes and a new depends. It felt like I looked away for 7 seconds and she had gone off the toilet. I told her to sit here because I have to get wash clothes . She did fall into the doorway, she didn't hit her head, and she did not get hurt. A day or 2 days later, whenever I came back to work my next shift, [V23] (Restorative Nurse) had pulled me aside and told me [R60] is a stand lift for transfers. The linens I went to get were on the linen cart right outside of the room . On 5/22/25 at 10:29 AM, V23 (Restorative Nurse) said, If I remember right the CNA said that she was getting anxious in the wheelchair, trying to get up, and needed the toilet. She went to put her on the toilet. She went to grab some linens to get ready to get her off the toilet . I believe the linens were on the bed. As soon as [R60] stood up she lost of balance and that's when she took that fall. Her gait is not the best and that is why she is non-ambulatory. The intervention started in response to that fall was to have the aide remain with her in the bathroom. The CNA should use the call light to have another staff member come assist her if the resident is noted to be anxious . On 5/22/25 at 1:32 PM, V3 ADON (Assistant Director of Nursing) said, . [R60] does get up on her own, actually just Monday I was walking down the hallway, and she was already standing up out of her wheelchair. She is not safe to leave alone in the bathroom. If they need something they should pull the call light and wait for someone to answer, or they could even holler out the door if need be. The facility's policy revised March 2018 showed, Falls - Clinical Protocol . Treatment/Management; 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling . The facility's policy revised July 2018 showed, Dementia - Clinical Protocol For the individual with confirmed dementia, the IDT (Interdisciplinary Team) will identify a resident centered care plan to maximize remaining function and quality of life .

Based on interview and record review, the facility failed to provide 2 residents (R6, R39) with dignity. This applies to 2 of 2 residents reviewed for dignity in the sample of 23. The findings include: 1) R6's electronic face sheet printed on 5/22/24 showed R6 has diagnoses including but not limited to major depressive disorder, anxiety disorder, and acquired absence of left leg above knee. R6's facility assessment dated [DATE] showed R6 has no cognitive impairment and reports feeling down, depressed, or hopeless nearly every day. R6's care plan dated 3/9/25 showed, I have expressed a problem with mood and depression and scored a 13 out of 27 on the PHQ9(Personal Health Questionnaire). As per section D of the MDS (Minimum Data Set), the areas of impact include feeling down, depressed, trouble staying asleep, feeling tired or having little energy, poor appetite and feeling anxious and restless. On 5/21/25 at 9:12AM, R6 stated, One night, (V13-Certified Nursing Assistant) told me that my thighs are too big. I didn't have any pants on at the moment because he was helping me get cleaned up. It made me feel awful and like he was looking at my naked body. On 5/22/25 at 10:52AM, V1(Administrator) stated there are no disciplinary actions in V13's employee file. As of 5/23/25, no social service documentation related to (R6's) alleged statements were present in R6's electronic medical record. The facility's document titled, Resident Concern Form dated 5/1/25 showed, Resident was upset by male staff. She said her told her that she had wide hips which made her feel bad about weight (fat). (V1) spoke with resident and daughter on 5/2/24. He spoke with (V13) regarding concern and asked him to apologize .Resident was pleased with administrator handling situation. She was asking for an apology, nothing more. On 5/22/25 at 1:35PM, R6 stated, (V13) never came and apologized to me for saying what he said. As far as I'm concerned, this hasn't been resolved because he should be held accountable for his statement and could at the very least apologize to me. On 5/21/25 at 2:40PM, V14 (Social Services) stated, (R6) brought up a concern to me regarding (V13) stating he said something to her about her thighs and it made her feel fat. I spoke with (R6) regarding the concerns right away then I handed it off to (V1) to take care of. (V13) was supposed to apologize for making any comment that (R6) may have taken negatively. I'm not sure if he did apologize or not but that was supposed to happen. The facility's policy titled, Quality of Life-Dignity with a review date of February 2020 showed, 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 .1. Residents are treated with dignity and respect at all times .7. Staff speak respectfully to residents at all times .11. Demeaning practices and standards of care that compromise dignity are prohibited . 2) R39's electronic face sheet printed on 5/22/25 showed R39 has diagnoses including but not limited to type 2 diabetes, adjustment disorder, wedge compression fracture of unspecified lumbar vertebra, major depressive disorder, and anxiety disorder. R39's facility assessment dated [DATE] showed R39 has no cognitive impairment and reports feeling down, depressed, or hopeless nearly every day. R39's care plan dated 4/18/25 showed, I have depression related to my admission to facility and current health condition that has caused me great pain and mobility limitation. I have diagnosis of Major Depressive Disorder and General Anxiety. I am having difficulty with my roommate and another female peer. I am a very private person and have asked for my roommate to not talk about me or discuss with others about my medications. I have declined to move to another room because I like my room and feels that moving is not the right solution for me. It is very stressful and tearful. On 5/21/25 at 9:23AM, R39 stated, One day I was in the break room with (V13) because he was helping me get snacks out of the vending machine. I couldn't find my magnifying glass, but I saw reflection over on the wall and when I reached next to me, I found my magnifying glass and (V13) said, You couldn't find it because your thighs are too big. Two weeks ago, he told my roommate (R6) that her hips were too big then he said, oh I won't tell (R39) she has big thighs again. (V14) was informed about it and said she would take care of it, but we never heard anything further. (R39 was tearful throughout entire conversation regarding incident with V13). On 5/21/25 at 2:40PM, V14 (Social Services) stated, (R39) will say she has concerns, you address it, she'll say she doesn't want them in her room, then she will come back and say she never said that. She didn't bring up (V13) to me until her roommate (R6) brought up a comment that she thought (V13) made a comment about her thighs. (R39) was looking for her magnifying glass and he said that's why you couldn't find it because you were sitting on it, he never referenced her weight. I usually don't fill out grievance forms for her because she never wants anything done. R39's social service progress notes were reviewed and showed no documentation related to any conversation regarding V13 or any concerns that R39 has had. The facility's grievances were reviewed for the past 6 months with grievances filed by R39. On 5/22/25 at 10:09AM, R39 stated, I was never told about any resolution with (V13), and he hasn't even come and apologized to me. They never follow-up with us on our concerns. I was told by (V14) that she handed off my concerns to (V1) and then never heard anything else. A phone call was made to V13 during the survey with no return call received.

Based on observation, interview, and record review, the facility failed to obtain orders for a residents (R9) CPAP (Continuous Positive Airway Pressure) machine, failed to document respiratory assessments for a resident utilizing a CPAP machine. These failures apply to 1 of 2 residents reviewed for respiratory care in the sample of 23. The findings include: R9's electronic face sheet printed on 5/22/25 showed R9 has diagnoses including but not limited to multiple sclerosis, muscle weakness, dysphagia, and obstructive sleep apnea. R9's May 2025 physician's orders showed no orders for R9's CPAP machine settings or cleaning. A review of R9's care plan showed no care plan related to R9's obstructive sleep apnea or interventions to manage R9's respiratory status. On 5/21/25 at 9:41AM, R9 stated, The staff take care of my CPAP for me. They have to help put it on me at night when I want it. They got me a new mask, but it doesn't fit right in my face. The one I got now works well. It's just one setting right now but I don't know what it is. I leave that to them to figure out what the doctor has ordered. On 5/22/25 at 10:23AM, V15 (Licensed Practical Nurse) stated, There is no order for (R9's) CPAP settings or cleaning schedule. There should be an order for settings and cleaning to ensure that we have her on the correct setting and the unit is being cleaned once a week. If we do not clean it, then bacteria could develop in the machines tubing and mask. Failure to have the correct settings could result in inadequate oxygenation for her. She used to have orders so I'm not sure why she doesn't now. The facility's policy titled, CPAP/BiPAP Support with a revision date of March 2015 showed, Purpose: 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive disease Preparation .3. Review the physician's order to determine the oxygen concentration and flow, and the PEEP (Positive End Expiratory Pressure) for the machine .Document the following in the resident's medical record: 1. General assessment (including vital signs, oxygen saturation, respiratory, circulatory, and gastrointestinal status) prior to procedure. 2. Time CPAP was started and duration of therapy. 3. Mode and settings for the CPAP .4. Oxygen concentration and flow, if used. 5. How the resident tolerated the procedure. 6. Oxygen saturation during therapy .

Based on observation, interview and record review the facility failed to provide physical therapy services to a resident as ordered for 1 of 3 residents reviewed for specialized rehabilitation services in the sample of 5. The findings include: R1's Admission Record dated 11/6/24 showed R1 was a [AGE] year old female admitted to the facility with diagnoses of lung cancer and pneumonia. R1's hospital discharge instructions dated 11/6/24 showed R1 was to receive physical therapy services, 1-2 times per day, Monday-Friday, while in the facility. A physician order for R1, dated 11/6/24, showed, Eval and treat-PT (physical therapy). On 11/13/24 at 8:23 AM, R1 was in bed. R1 stated, I came here to get stronger so I could go home to my kids. I am not getting any physical therapy. I have gotten OT (occupational therapy) but I need to get stronger so I can get out of bed . R1's therapy records dated 11/6/24-11/13/24 were reviewed. The records showed she was evaluated by occupational therapy on 11/7/24. R1 received occupational therapy services on 11/8/24 and 11/11/24. The records showed no physical therapy evaluation was completed on R1. R1 had not received any physical therapy services in the facility. On 11/13/24 at 10:26 AM, V7 Director of Rehab stated, Our goal is to have any newly admitted resident assessed by therapy within 24 hours of admission. V7 stated R1 had been assessed by the occupational therapist upon admission but had yet to be assessed by a physical therapist. When V7 was asked why R1 had not been assessed by a physical therapist, V7 stated, It was a scheduling thing. Our therapists come PRN (as needed) and our therapy assistants do the daily treatments. Our occupational therapist was here last week and could see (R1) right away. Our occupational therapist thought (R1) would be tired from the OT so we didn't have our physical therapist see (R1) . V7 stated she was unaware of R1's hospital discharge (therapy) instructions. On 11/13/24 at 12:50 PM, V2 Director of Nursing stated, We dropped the ball. We should have had the physical therapist evaluate (R1). The facility's Functional Impairment-Clinical Protocol policy dated March 2019 showed, The physician will identify and document the impact of medical conditions on function and identify a resident's/patient's potential to benefit from rehabilitation services such as physical and occupational therapy . The physician will order any therapy services based on above considerations . The facility's Scheduling Therapy Services policy dated July 2019 showed, Therapy Services shall be scheduled in accordance with the resident's treatment plan . The therapist shall interview the resident and consult with the Attending Physician as to the type of treatment to be administered .

Based on observation, interview, and record review the facility failed to ensure there was no delay in notifying a dietitian of severe weight loss in residents and failed to ensure there was no delay in implementing the dietitian's recommendations for residents with severe weight loss. This failure resulted in the delayed treatment and monitoring of residents with severe weight loss. This applies to 3 of 3 residents (R27, R339, R61) reviewed for severe weight loss in the sample of 18. The findings include: 1. R27's Weights and Vitals Summary report showed on 9/5/23 R27 weighed 127.5 pounds and on 10/4/23 weighed 112.4 pounds. A severe weight loss of 13.4% in one month. R27's Progress Note dated 10/12/23 showed the dietitian recommended R27 to receive a dietary supplement twice a day. R27's Progress Notes dated 10/16/23 showed the doctor was notified of the dietitian's recommendations. A fax to R27's physician dated 10/18/23 showed the physician was notified for a second time of the dietitian's recommendation made on 10/12/23 for R27 to receive a dietary supplement twice a day. R27's Progress Notes dated 10/18/23 showed the doctor agreed with the dietitian's recommendation. R27's Physician Order Summary showed the dietitian's recommendation for the supplement was started on 10/19/23 (15 days after R27's weight lost was identified). On 6/11/24 at 11:00 AM, V6 (Dietitian) said she would expect to be notified of a resident's significant/severe weight loss as soon as possible so the resident can be evaluated, and interventions started if needed. V6 said the process can take up to one week. V6 said in October 2023, she was transitioning into the role as the facility's dietitian and was not sure why there was a delay in addressing R27's weight loss. V6 add that a significant/severe weight loss is considered a change in the resident's condition. On 06/11/24 at 1:25 PM, V5 (Dietary Manager) said the normal time frame for notifying the dietitian of a significant weight loss and the implementation of the dietitian's recommendation is no longer than a week. V5 said she was not sure why there was a delay in addressing R27's weight loss as she was new to the role of dietary manager in October 2023. R27's Care Plan showed R27 was at risk for unplanned weight loss. 34314 2. R339's face sheet lists his diagnoses to include: chronic obstructive pulmonary disease, chronic respiratory failure, dysphagia, unilateral inguinal hernia, congestive heart failure, alcohol dependence disorder, dementia, and alcohol abuse. On June 11, 2024 at 9:45 AM, R339 was awake lying in bed. R339 was very thin and stated, he has lost weight. R339 was not sure why and that he just wasn't hungry. R339's weights and vitals summary shows, his weight on May 6, 2024 was 113.6 lbs. (pounds) and was 99.4 lbs. on May 20, 2024 (14 lbs. weight loss, 12.50%, 14 days later). R339's electronic medical records shows, the last time he was seen by the dietitian was on April 28, 2024. The progress note shows, RD [registered dietitian] WT [weight] REVIEW/WEIGHT WARNING: Value: 110.4#, BMI [body mass index] 20 low for age. sig [significant] wt. loss x 1 month noted. Overall weight is now slightly more stable x 2 weeks . REVIEW: res [resident] recently downgraded diet to mech soft [mechanical soft] for pocketing/chewing difficulty. He does have CHF [congestive heart failure] and some fluid shifts likely causing weight loss/gain. REC: add house supplement/ensure BID [twice daily] for supplement and weekly weights- monitor on NAR [nutrition risk assessment]. R339's electronic medical record shows, he has not been weighed weekly. The last weight record was May 20, 2024. R339's electronic medical record does not show, an order for weekly weights. R339's progress notes dated May 20, 2024 shows, Call placed to son/POA [power of attorney] to inform of weight loss and poor appetite. Message left to call facility. Referral to dietician. MD [medical doctor] updated. R339's electronic medical record does not show any new orders or interventions in place following his 14 lbs. 12.50% weight loss in 14 days. On June 11, 2024 at 11:22 AM, V6 Dietitian stated, she was aware of R339's weight loss. V6 said she asked the facility for a re-weigh to ensure the May 20, 2024 weight was correct. V6 said she has not put any interventions in place because he hasn't been re-weighed. V6 said the facility should be following her recommendations of weekly weights. 45540 3. R61's Weights and Vitals Summary report showed on 5/6/24 R61 weighed 168.5 pounds and on 6/2/24 weighed 159.4 pounds. A severe weight loss of 5.4% in one month. On 6/11/2024 at 11:10 AM, V6 (dietitian) said she recommended weekly weighs for [R61] because he was being monitored for weight loss following a hospitalization . R61's Progress Notes entered on 5/21/2024 by V6 states, continue on weekly weights and monitor via NAR. R61's Weights and Vitals Summary dated 6/11/2024 shows a weight of 159.4 lbs. on 6/2/2024 with no additional weight listed to current (6/11/2024). R61's Care Plan dated 5/16/2024 states, Weigh me as ordered and notify my nurse, my physician, the dietary manager, and the dietitian of any significant weight loss. On 6/11/2024 at 2:04 PM, V2 Director of Nursing (DON) said the dietitian's frequency of weight recommendations should be followed for residents. The facility's weight change assessment and intervention dated September 2018 shows, Policy Statement: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy interpretation and implementation: Weight assessment: 2. Weights will be recorded in the individual's medical record. 3. Any weight change of 5% or more since the last weight assessment, If the weight is verified, nursing will notify the Dietitian and MD/NP (medical doctor/nurse practitioner).

Based on observation, interview and record review the failed to prevent a resident from developing pressure injuries and failed to identify pressure injuries prior to becoming stage 3, and unstageable for 1 of 3 residents (R1) reviewed for pressure injuries in the sample of 3. The findings include: R1's census report shows she was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses include obesity, hemiplegia and hemiparesis following a cerebral infarction affecting left non dominant side. The facility assessment of 11/30/23 documents R1 is a moderate risk for developing pressure sores due to being chairfast and very limited mobility. The 10/27/23 care plan documents R1 is at risk for impaired skin integrity related to advanced age, decreased mobility, diabetes, and a history of pressure injuries. R1's December 2023 TAR (Treatment Administration Record) shows an order upon admission to notify the MD with any change in skin/document every night shift for admission. The wound rounds report shows an unstageable wound to the right heel identified on 11/28/23. R1's care plan documents a blister to the right heel, and on 12/5/23 the blister increased in size and measured 5 cm (length) by 5.2 cm (width) and was full of fluid and dark dry surrounding edges. The notes show podiatry was managing the heel wound. R1's 11/13/23 podiatry progress notes show she had no pressure wounds or concerns with her heels. The 12/8/23 progress note shows she had developed wounds to her bottom and now to her right heel. The exam shows a 4 cm by 3 cm fluid filled pressure blister located to the posterior right heel. The 12/27/23 progress notes show the wound to be 4.5 cm x 3.5 cm and 0.1 cm (depth). The plan of care shows R1 was recommended for the initiation of local wound care and follow-up with the wound center. R1's 12/4/23 progress notes for skin/wound note shows V6 LPN/ wounds (Licensed Practical Nurse) documented a stage 3 pressure wound identified on the left buttock. The wound measured 2.2 cm wide by 1.2 cm in depth and 0.1 cm. V6 noted R1 had a decline in mobility and spending more time in bed related to a recent diagnosis of Covid 19. R1's initial physician wound evaluation and management summary of 12/7/23 shows V7 (Wound physician) assessed the left medial buttock to have a stage 3 pressure wound measuring 1.0 cm (length) by 0.7 cm (width) and 0.3 cm (depth). On 1/24/24 at 2:15 PM, V6 stated she initially identified the buttock wound at a stage 3. It had not been reported to her by staff. V6 was in R1's room and did a skin check on her buttocks. V6 said pressure wounds should be identified prior to a stage 3 and should be found at a stage 1. V6 said R1 had covid and was wanting to stay in bed longer, and her mobility had declined, which puts her at a higher risk for skin breakdown. V6 said R1 should have had a skin check daily, and the wound should have been identified earlier. V6 said the blister on R1's heel was caused by friction/pressure. On 1/24/24 at 10:47 AM, V5 CNA (Certified Nursing Assistant) said R1 is alert and knows what is going on. R1 can be non-compliant with some care, she likes to be sitting in her chair. V5 said R1 can move herself but must have help to get R1 onto her side. R1 cannot move her legs and get them up on the bed. Once on her side, R1will stay in that position. On 1/24/24 at 10:40 AM, R1 said she has pain on her bottom because she was sitting in the chair too long and staff did not turn her. R1 was observed using the upper side rail to sit up to the edge of the bed and said oh my butt when she sat up straight. On 1/24/24 at 11:45 AM, R1's wound to the buttocks was observed to be clean, no redness noted on the edges, and no drainage. On 1/24/24 at 10:23 AM, V4 LPN said when R1 is in bed she can move her upper body, maybe shift herself, but cannot reposition herself. Staff has to make sure to move her side to side. V4 said skin checks are done with showers and the CNAs report any redness, open areas, or bruising to the nurse and mark the shower sheets. On 1/25/24 at 11:20 AM, V11 FNP (Family Nurse Practitioner) of podiatry said R1's heel ulcer could have been prevented. She has been seeing R1 as a patient for a very long time, and she had no problems with pressure injuries until she went to the nursing home. V11 said if (R1) was on daily skin checks, the nurse would have noted the heels to be reddened or maybe a little purple before having a pressure blister. V11 said if a wound is not identified, and no treatment or prevention is put in place the wound will become advanced (worsen). V11 said R1's heel had worsened and was referred to the wound clinic for further care and treatment. On 1/24/24 at 2:40 PM, V9 LPN said residents get repositioned every 1.5 to 2 hours. When performing a skin check, areas checked would include the buttocks, any bony prominence and the heels to see if any wounds or breakdown are present. V9 said any open areas are documented in the progress notes and reported to V6, and the physician. Residents are on daily skin checks, and it is noted on the TAR. On 1/25/24 at 11:20 AM, V12 FNP usually said skin issues can be found during showers, toileting, and giving care. V12 said, I would expect wounds/skin issues to be identified a stage 1 when the skin is becoming reddened and even at a stage 2 when the skin is starting to open up. Something should have been noticed sooner. It is not typical for a non-terminal resident to develop pressure wounds in just a few hours. If she (R1) had been turned or taken to the bathroom, they should have noticed. The facility's July 2017 policy for prevention of pressure ulcers/injuries document the purpose is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Risk Assessment 4. Inspect the skin on a daily basis when performing or assisting with personal care or ADL's (activities of daily living). a. Identify any signs of developing pressure injuries b. inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.).

Based on observation, interview, and record review the facility failed to identify a resident as high risk for pressure ulcers, failed to implement interventions to prevent a pressure ulcer from reoccurring, and failed to implement pressure relieving interventions. These failures contributed to R12 developing a deep tissure injury on his left hip and R9 developing five new stage II pressure ulcers. This applies to 3 of 6 residents (R3, R12, R9) reviewed for pressure ulcers in the sample of 17. The findings include: 1. R12's Physician order [REDACTED]. The Minimum Data Set (MDS) of June 2, 2015 shows R12 has severe cognitive impairment and requires extensive assistance from staff with transfers, eating, dressing, hygiene, bathing, and toileting. The June 2, 2015 MDS shows R12 has history of pressure ulcers. R12's Pressure Sore Risk assessment dated [DATE] shows R12 is high risk for pressure ulcers. R12's Pressure Ulcer care plan dated April 6, 2015 shows Pressure reducing devices (cushions). R12's scrotum pressure ulcer care plan dated May 24, 2015 shows assist with toileting and repositioning every 2 hours and PRN. R12's Pressure Sore Weekly Flow Sheet shows R12 had a stage II pressure ulcer to his left ischium develop on September 9, 2014. The Pressure Sore Weekly Flow Sheet shows R12 had a stage II pressure ulcer develop to his scrotum on September 22, 2014. R12's treatment record shows an order on June 25, 2014 moderate risk skin check night shift on Wednesday, Saturday. R12 was not assessed as high risk (requiring daily skin assessments) until January 6, 2015, almost 4 months after he developed his second pressure ulcer. On June 4, 2015 at 1:50 PM, R12 was in bed lying on his right side. R12 had an irregular shaped, circular, purple discolored area to the left hip. E21 (Licensed Practical Nurse -LPN) said R12 had a previous pressure ulcer to his left buttock but it was healed, and said the purple discolored area was new and she would consider it a stage I or stage II. The nurse note dated June 4, 2015 at 2:45 PM shows Purple bruised area to left hip found today. Measures 4cm x 2 cm, red area around it 7cm x 4.5cm, tender to touch. The nurse note dated June 4, 2015 at 5:13 PM shows Area on left hip appears to be possibly a DTI (deep tissue injury). On June 5, 2014 at 8:40 AM, R12 was sitting in his wheelchair with a lift sling under his buttocks. E32 (LPN) checked under R12's bottom and said he did not have a pressure relieving cushion in his wheelchair. On June 5, 2015 at 9:15 AM, R12 was still sitting in his wheelchair in the activity room with a cushion. On June 5, 2015 at 10:00 AM, E13 and E16 (Certified Nurse Assistants - CNA) said R12 had been up since approximately 6:30 AM, when they got him up before breakfast. On June 5, 2015 at 10:00 AM, E13 and E16 said R12 does not have a set schedule or set times in which he should have pressure relieved from his bottom during the day. E13 and E16 said R12 does not have a schedule in which he goes to bed to relieve pressure to his bottom. E13 and E16 said some days he will lay down after meals and other days he stays up in his chair most of the day. On June 5, 2015, E4 (MDS Coordinator) said there are several factors used to determine if a resident is at high risk for skin breakdown. E4 said if a resident has a history of a previous pressure ulcer, they would automatically be high risk for developing another even if the skin assessment tool does not identify them as high risk. On June 5, 2015, at 8:40 AM, E2 (Director of Nursing - DON) said a daily skin check is done to make sure no skin breakdown is occurring and to identify skin concerns early. E2 said there should be preventative measures in place if a resident has a pressure ulcer and it heals. E2 said if a resident has a pressure ulcer, or a history of a healed pressure ulcer they would be considered high risk and should have daily skin assessments. E2 said a deep tissue injury would be considered a pressure related injury. The facility Prevention of Pressure Ulcers dated November, 2013 states Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation.The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. For a person in bed - change position at least every two hours or more frequently if needed. For a person in chair - Use foam, gel or air cushion as indicated to relieve pressure. The facility Braden Risk Preventative Measures policy dated November, 2013 states Severe and High Risk - skin checks should be done daily. Moderate Risk - skin checks should be done 2x per week. 2. R3's May 1, 2015 POS shows [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) of May 9, 2015 shows R3 requires extensive staff assistance with transfers, dressing, hygiene, bathing, and toileting. The May 9, 2015 MDS shows R3 has severe cognitive impairment. The Weekly Pressure Ulcer flow sheet shows R3 had a stage II pressure ulcer to her left inner buttock on January 23, 2015. R3's POS dated June 1, 2015 shows an order on September 10, 2014 for bilateral heel protectors when in bed each shift and on December 9, 2014, dimethicone to buttocks and peri-area with each incontinent episode and PRN. On June 2, 2015 at 1:30 PM, E16 transferred R3 to the toilet with a mechanical stand lift. R3 was incontinent of urine from the wheelchair to the bathroom. E16 provided incontinence care to R3 but did not apply barrier cream prior to transferring her from the bathroom to bed. E16 positioned R3 on her left side and did not put heel protectors on her prior to covering her up and leaving the room. On June 4, 2015 at 1:30 PM, E16 said R3 only wears heel protectors when she is in bed at night. On June 4, 2015 at 10:00 AM, E2 said R3 should have barrier cream put on after each incontinent episode and with peri-care. The MDS of May 4, 2015 shows R9 is a [AGE] year old with a history to include Stage 3 Kidney disease, [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. R9 was admitted to the facility on [DATE] with open wounds on his buttocks and readmitted on [DATE] with no open wounds. R9 requires extensive assistance with bed mobility, transfers, and toilet use. On June 2, 2015, R9 was sitting in his wheelchair in his room at lunch time, and in the afternoon. On June 3, 2015, R9 was sitting in his wheelchair in the morning, at lunch time, and at 4:00PM On June 4, 2015, R9 was sitting in his wheelchair in the morning, at lunch time, and at 4:00PM. On June 5, 2015, R9 was sitting in his wheelchair in the morning, at lunch time, and at 4:00PM. During observation R9 was not assisted or encouraged to change positions. On June 2, 2015 at 11:30, R9 said sometimes staff comes in his room [ROOM NUMBER] or 2 times a night and sometimes I don ' t see staff all night. They need to hire more staff. R9 states, I ' m in the chair pretty much all day. On June 2, 2015 at 12:30PM, Z4 said (R9) stays in his wheelchair all day unless he ' s in therapy. Call light times are long. I don ' t think they have enough staff to take care of everybody. On June 3, 2015 at 12:30PM, Z5 said call light times are long, and that more staff needs to be hired to care for all these people. On June 3, 2015 at 1:00PM E18 RN (Registered Nurse) said R9 has five new stage 2 pressure ulcers on his buttocks. Two sores on the right buttocks, and three sores on the left buttocks. The May, 2015, The MAR (Medication Administration Record) shows a liquid nutritional supplement was ordered on May 8, 2015 three times a day for 10 days. Out of the 30 doses R9 should have received, only 2 doses are signed as given. On June 4, 2015, at 2:00PM E2 DON (Director of Nursing) said she is not sure why R9 did not get his liquid nutritional supplement three times a day from May 8 to May 18, 2015. E2 was unsure why an alternate liquid nutritional supplement was not offered. E2 said proper nutrition was important in the healing of wounds. The April 15, 2015 care plan shows, Problem: At risk for skin breakdown, Goals: Not acquire any new pressure ulcers, and intervention: Reposition every 2 hours or as indicated by resident need, provide reminders to reposition. The MDS dated [DATE], and June 4, 2015 shows R9 ' s bed mobility as needing extensive assistance. R9 ' s nursing progress notes, MAR ' s and TAR ' s (Treatment Administration Record) from April 15 through June 6, 2015 shows no documentation of R9 being repositioned or reminders/encouragement to reposition. The June 3, 2015 skin risk assessment tool rated R9 as 14 which is moderate risk. The CNA skin check detail report on June 2, 2015 at 11:16PM, and on June 3 at 7:55AM shows R9 had no new skin problems. The Accident/Incident/Unusual Occurrence Report dated June 3, 2015 at 8:00 AM, shows E18 RN found Five stage 2 pressure ulcers on R9 ' s buttocks. The November, 2013 pressure ulcer/skin breakdown policy states 1). The nursing staff and attending physician will screen and document an individual ' s significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and history of pressure ulcer(s). 2). In addition, the nurse shall monitor and document/report .e. Resident ' s mobility status. The same policy states, under the heading, Prevention of Pressure Ulcers , General Guidelines. 1). Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue.

Based on observation, interview, and record review the facility failed to supervise a resident with dementia to prevent a fall, the facility failed to ensure a resident bed was in a locked position, the facility failed to have staff available to assist a resident at risk for falls. The facility failed to safely transfer residents with the use of mechanical lift devices. These failures contributed to R3 sustaining fractures to two cervical vertebrae (C1, C2). This applies to 4 of 17 residents (R3, R7, R1, R14) reviewed for safety in the sample of 17 and 1 resident (R21) in the supplemental sample. The findings include: 1. On June 2, 2015 at 11:50 AM, R3 was leaning forward in her wheelchair at the dining room table with a soft neck brace on. R3's May 1, 2015 POS (Physician order [REDACTED]. The MDS (Minimum Data Set) of May 9, 2015 shows R3 requires extensive staff assistance with transfers, dressing, hygiene, bathing, and toileting. The May 9, 2015 MDS shows R3 has severe cognitive impairment. R3's August 20, 2014 and February 18, 2015 fall risk screening tools shows R3 is high risk for falls. R3's nurse note entry dated September 9, 2014 shows Called to B1 hallway approximately 6:45 AM. Resident on floor with moderate amount of bleeding coming from her head. Assessment obtained as well as I could. Resident has impaired cognition.Sent to ER for Evaluation. R3's nurse note entry dated September 9, 2014 at 2:37 PM states called to check resident status. Informed resident taken to (medical center) with C1, C2 (cervical neck) fractures. The facility Accident/Incident/Unusual Occurrence Statement dated September 7, 2014 shows E29 (CNA -Certified Nurse Assistant ) wrote I came out of a residents room, and heard (R3) yelling. I walked to the activity area and saw (R3) on the floor in front of the wheelchair. I notified the nurse and applied pressure to her head wound. R3's emergency room note dated September 7, 2014 shows The patient presents following fall out of a wheelchair at the nursing home and closed fracture of the cervical vertebra. On June 6, 2015 at 5:20 PM, Z3 (Primary Medical Doctor) said the residents with dementia on the B wing need more supervision and should not be left unsupervised in the B wing activity room. On June 4, 2015 at 1:30 PM E16 (CNA) said the B Wing activity room is not supposed to have residents in it unless there is a staff member or nurse in the room with them. E16 said she was working the morning R3 fell . E16 said I was still getting people up and was in a resident room when she (R3) fell . E16 said R3 is in the B wing activity room for supervision and because she is high risk for falls. On June 5, 2015 during a confidential staff interview, it was stated there are many times there are not any staff members in the B wing activity room with the residents in the morning until the activity staff arrives. It was also stated there is usually only two CNAs until around 8:00 AM and the CNAs cannot see into the activity room while they are getting residents up. On June 4, 2015 at 1:15 PM, E35 (Activity Aide) said residents are not supposed to be in the B wing activity room unless a staff member is present. E35 said everyone on the B wing is considered high risk for falls because they have dementia. E35 said the activity department works in the activity room from 8:00 AM until 9:00 PM and if a resident is up before 8:00 AM a nurse or a CNA is supposed to stay with them. On June 4, 2015 at 10:00 AM, E2 (Director of Nursing- DON) said R3 was left in the B wing activity room unsupervised when she fell on [DATE]. E2 said the residents on the B wing should be under direct supervision at all times while up because they are at a high risk for falls and most have dementia. The facility Fall Management policy states The staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The May, 2015 Fall Prevention Activities Pre and Post Falls shows As a fall occurs.the plan of care will be updated.The revisions to the fall care plan will be monitored for effectiveness and adjustments made as needed. 2. On June 2, 2015 at 1:30 PM, E16 (CNA) attached a stand lift sling to R3. E16 had to assist R3 by placing her hands on the standing mechanical lift hand bars. Without attaching the lift leg strap around R3's legs, E16 raised R3 to a standing position and took R3 into the bathroom. R3 let go of the stand lift with her her right arm while she was wheeled into the bathroom. After R3 was finished in the bathroom, E16 used the mechanical lift to raise R3 to a standing position. R3 was not holding onto the lift with her left or right hand. E16 did not prompt R3 to hold onto the handles, and did not attach the strap to R3's legs. E16 said R3 does not step off the lift so she does not need the leg strap secured around her legs. E16 said the CNAs know if someone will step off and if they do, they use the leg strap on them. On June 4, 2015 at 10:00 AM, E2 said the restorative CNAs assess the appropriateness of resident transfers. E2 said after they assess the resident, they notify her and she updates the care plan. E2 said if a resident is unable to hold on to the handles on the mechanical stand lift, the resident should be changed to a mechanical lift. E2 said it is not a safe transfer if the resident cannot hold onto the handles on the mechanical stand lift. E2 said it would depend on the situation whether or not the leg strap should be used, and she has not care planned the leg strap as needed for any residents, and she is not sure when it would be needed. The facility policy Safe, Lifting, and Movement of Residents dated November, 2013 shows Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices. The facility undated Owners Operator and Maintenance Manual states secure legs prior to transfer of the resident and instruct the patient to hold onto the hand grips on both sides of the stand up lift. 3. R12's care plan dated May 24, 2015 shows [DIAGNOSES REDACTED]. The MDS of June 2, 2015 shows R12 has severe cognitive impairment and requires extensive assistance from staff with transfers, eating, dressing, hygiene, bathing, and toileting. This MDS shows R12 has a history of falls. R12's May 12, 2015 Fall Risk Screening Tool shows R12 is at a high risk for falls. On June 5, 2015 at 9:15 AM, R12 was in the B wing activity room, sliding out of his wheelchair. E32 Licensed Practical Nurse (LPN) was holding onto R12 and calling for a CNA to help her. R12's January 12, 2015 at 12:06 AM nurse notes shows CNA entered the room for 12 midnight rounds. Patient legs and buttocks are in the bed, his head and shoulders are on the floor between the wall and the bed frame. The bed is not locked and has rolled away from the wall. Patient assisted up into the bed. He has an indentation on his left temple from pressure against the soft foam wall guard. His face appears puffy and reddened. On June 5, 2015 E2 (DON) said a resident bed should be locked at all times to prevent the bed from moving. E2 said R12's bed positioned up against the wall but moved because it was unlocked. On June 5, 2015 at 10:00 AM, E16 (CNA) said a resident bed should be locked. 4. R7's POS shows [DIAGNOSES REDACTED]. R7's Minimum Data Set (MDS) of March 1, 2015 shows R7 requires extensive assistance from staff with transfers, dressing, eating, hygiene, bathing, and toileting. On June 2, 2015 at 11:20 AM, E16 (CNA) placed a mechanical stand lift sling on R7. Without attaching the leg strap, E16 raised R7 to a standing position from her wheelchair and transferred her to the toilet. E16 transferred R7 back to her wheelchair with the mechanical stand lift without securing R7's legs with the leg strap. E16 said she only uses the leg strap on certain residents who move their legs away from leg rest on the lift. E16 said the straps are used to keep the legs on the lift and prevent the residents from lifting their leg up or stepping off the lift. 5. On June 2, 2015, at 9:27 AM, E12 (CNA) and E17 (Nursing Assistant - NA) performed a mechanical lift transfer on R1. E17 used the lift controls as E12 stood behind R1 to guide his body. R1 was removed from his wheel chair at the foot of the bed and then moved over to the side of the bed. During the transfer, R1's body was aligned with his legs facing and intermittently touching the support bar and his back to E12. Once the CNA's had R1 at the side of his bed, E17 realized she had not lowered the side rail of the bed. E17 left the controls to lower the side rail. E17 had difficulty lowering the side rail as the bed side table was blocking the lowering of the rail. E12 told E17 to pull the side table out from the wall and move it to get the side rail lowered. E11 was still holding onto R1's torso/back, however, while trying to explain how to lower the side rail to E17, R1's legs were pushed into the mechanical lift support bar. R1 began screaming out in pain and saying ouch my legs, your hurting my legs. You are pinching my legs! E17 returned to the controls of the lift and attempted to pull R1's left leg to the opposite side of the support bar so that he had a leg on each side. R1 continued to scream and said don't pull on it your hurting me! R1's medical record showed he has multiple medical [DIAGNOSES REDACTED]. The facility's policy titled Lifting Machine, Using a Portable, revised November 2013, under the section to put the resident back to bed, showed the following: f. Assist the resident in guiding his or her legs. g. Move the lifter away from the chair. Be sure the resident is turned in such a manner that the resident is facing you. Do not pull the resident backwards. 6. On June 2, 2015 at 10:05 AM, R14 was in her room on the A wing hallway. R14 was seated in a recliner at a 45 degree reclining position with her feet elevated. The recliner was located in the corner of the room with a nightstand between the recliner and the bed. R14's call light was on the far side of the bed, near the center of the room and inaccessible to R14. R14 stated she needed to use the bathroom and was unable to get there without assistance. R14 stated she had no way of getting the attention of the staff. R14 stated someone came in earlier and said they would be right back but never came. E13 (CNA), the B wing CNA came to R14's room at the request of the surveyor. E13 looked into R14's room and stated R14's call light was not within reach. E13 stated call lights are to be with in the residents reach at all times. R14 told E13 I think I have already gone (urinated in her clothing) waiting for assistance. The Minimum Data Set (MDS) dated [DATE] showed R14 requires extensive physical assist of staff for ambulation. The fall risk assessment of April 1, 2015 scored R14 as a 16 (greater than 14 is high risk for falls.) On June 4, 2015, during a confidential staff interview, it was said that during meal times, the B wing is left unattended. The interviewee said because the staff are busy feeding residents who require assistance, they (staff) are unable to be on the unit. It was stated that staff have no way of knowing if a resident is taken back to the unit unless they happen to see it. It was stated that when and if someone is taken back to the B unit or needs to return to use the bathroom, the residents being fed must be left unassisted. On June 4, 2015 at 8:10 AM, R21 was brought from the dining room back to the B wing and left sitting in front of his room door. The unit was unattended by staff. R21's medical record showed his fall risk assessment of April 20, 2015 scored him as a 30 (14 or greater is high risk). The facility's policy and procedure titled Answering the Call Light, revised November 2013 showed call lights are to be answered as soon as possible. If you have promised the resident you will return with an item or information, do so promptly. If assistance is needed when you enter the room, summon help by using the call signal.

Based on observation, interview, and record review the facility failed to ensure staff performed interventions as planned for a nutritionally compromised resident. The facility failed to review and revise inventions to address R9's poor oral intake. These failures contributed to R9's severe unplanned weight loss of 13.8 pounds in one month, and the development of a multiple pressure wounds. This applies to 1 of 10 residents (R9) reviewed for weight loss in the sample of 17. The findings include: The MDS (Minimum Data Set) dated May 4, 2015 shows R9 has a history to include recent deep vein [MEDICAL CONDITIONS] embolism, [MEDICAL CONDITION] stage 3, [MEDICAL CONDITION], ilieostomy/hemicolectomy, [MEDICAL CONDITION], and recent [MEDICAL CONDITION]. R9 was admitted to the facility on [DATE] at a weight of 146.3 pounds and on May 24, 2015 R9 was 128.5 pounds. On June 2, 2015 at 11:50 AM staff brought R9 his lunch, which was fish, cheesy rice, and spinach. Staff did not monitor R9's consumption, provide any verbal encouragement or request suggestion for alternate food items. Z4 replaced R9's meals with a peanut butter and jelly sandwich without asking R9 if he would prefer something else. On June 3, 2015 and June 6, 2015 R9 did not receive a morning snack. R9 was not on the June 5, 2015 facility list of residents to receive morning snacks. R9's current plan of care stated he was to receive one-on-one attention at meals and he was to receive a daily morning snack. The May, 2015 MAR (Medication Administration Record) showed R9 had a nutritional supplement ordered three times a day, from May 8 to May 18, 2015. The same MAR indicated [REDACTED]. On June 4, 2015 at 2:00 PM, E2 DON (Director of Nursing) was unsure why R9 did not get his physician ordered supplements. E2 said it may have been a supply issue. E2 was unsure why an alternative was not offered or why the physician was not called. E2 said R9's meal intake should be documented in his progress notes. The progress notes from April 15, 2015 to June 6, 2015 do not show staff had monitored, reviewed, or documented R9's meal consumption. On June 2, 2015 at 11:30 AM, R9 said sometimes I don't get my snack, and it's when I do not it may be something I do not like to eat. When I don't like the meal the staff only give me a peanut butter and jelly sandwich. R9 said I do not get supplement all the time. On June 2, 2015 at 12:30 PM, Z4 said the food is often served late and it is cold when served to (R9). Z4 has told the kitchen what (R9) likes and dislikes but (R9) is still served food he doesn't like. Z4 said at times (R9) does not get his liquid nutritional supplement, or his snack. On June 3, 2015 at 11:45 AM, Z5 said (R9) likes oatmeal with honey but the facility was not providing honey. Z4 brought in single serving packets of honey for R9. The Clients by Vital Parameter , weight documentation shows on April 21, 2015 R9's weight was 142.3 pounds. The same document shows on May 23, 2015 R9's weight was 128.5, a loss of 13.8 pounds or 9% in one month. The May 5, 2015 nutritional assessment sheet shows R9's food intake was between 26-75%. No documents were found or provided to document percentage of food consumed. On May 21, 2015 the nutritional progress notes shows R9's blood [MEDICATION NAME] level was 2.7 g/dl (grams per deciliter). The June 3, 2015 the nutrition assessment/data collection sheet shows R9's blood [MEDICATION NAME] level at 1.8 g/dl. Tthe computerized care plan does not include approaches for weight loss, A hand written care plan was presented dated May 5, 2015, which includes approaches to stem weight loss. Iinterventions that include: 1. Determine food preferences through one-to-one interview and/or family interview. 2. Provide one-to-one staff intervention and attention. 3. Dietary supplements as ordered. 4. Encourage and praise the resident's attempts to follow the prescribed diet. 5. Offer between meal, and bed time snacks. The November, 2013 policy on unplanned weight loss states, 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. 2. As part of the initial screening, the staff and physician will define the individual's current nutritional status and identify individuals with .recent weight loss and significant risk for impaired nutrition. Under Monitoring , The policy states. 1. The physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include: a. Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals; (1) Evaluating the resident's response to interventions should be based on defined criteria for improvement/worsening of nutritional status.

Based on observation, interview, and record review the facility failed to notify a physician when two residents exhibited significant declines in their physical condition. This failure resulted in a delay of treatment and hospitalization for R1 and R2. This applies to 2 of 3 residents (R1 & R2) reviewed for a change in condition in the sample of 9. The findings include: 1. R1's hospital discharge notes dated 12/27/14 showed a written order to specifically notify the physician, "If the patient has any sudden shortness of breath or sudden weight gain." The facility's document titled, Residents at Risk for Readmission Assessment, dated 12/29/14 identified R1 has having a history of Pneumonia. On 1/27/15 at 10:11 AM, E9 (Restorative CNA) stated on 1/24/15, (Saturday), she observed R1's call light on and went to assist him. E9 said R1 told her he "didn't feel right and that his left arm felt prickly." E9 said he "just didn't look right." E9 said she reported R1's expressed concerns to E6 (Registered Nurse - RN). On 1/27/15 at 12:41 PM, E6 (RN) stated she worked with R1 on Saturday (1/24/15) and Sunday (1/25/15) on the day shift. E6 stated R1 complained of "feeling weaker" on Saturday and was "running a low grade temp (temperature) of about 99 degrees Fahrenheit." (Elevated temperature not documented.) E6 stated she asked Z2 (Physical Therapist) to check his extremities. On 1/27/15 at 11:55 AM, E4 (LPN) stated he received report for the PM shift on 1/25/15 from E6 (RN). E4 said E6 reported R1 "was not feeling well and was running a low grade temp (temperature) so he stayed in his room most of the day." E4 said between 6:30 PM and 7:00 PM, Z10 called and told him R1 was "short of breath (SOB) and weak" and she (Z10) wanted him to go to the hospital. E4 said he went to R1's room to check his vital signs and obtained an SPO2 (blood oxygen saturation reading) of 75%. (Normal values 95-100%). E4 said the Oxygen was applied at 2 Liters (L) via nasal cannula with no change in saturation. E4 said he then "bumped it up to 3L" and obtained an SPO2 reading of 80%. E4 said, "at about that time the EMT's (Emergency Medical Technician's) arrived." E4 said "The ambulance personnel told me (Z10) called 911." E4 said he did not observe any physical signs of distress other than "an increased respiratory rate." E4 did not document R1's vital signs. E4 stated if a resident is "critical" then he would call 911, otherwise he would notify the resident's physician of a change in condition. A nursing note dated 1/23/15 at 6:49 PM showed R1 was exhibiting some mood swings through out the day. A nursing note entry dated 1/25/15 at 7:00 PM documents R1's decline as follows: "This nurse received phone call from (Z10) about (R1) informing me (E4) resident isn't feeling well. Assured (Z10) that I (E4) would go in and assess him (R1). Obtained V/S (vital signs). Unit A Nurse (E12 LPN) obtained O2 sat (saturation) of 75% on room air. Applied O2 at 2L/min per standing order. Lung sounds clear, diminished and breathing at a rate of 24 BPM (beats per minute). O2 sats up to 80% at 3L/min. A nursing entry made by E12 on 1/25/15 at 9:35 PM showed, "received phone call from (local hospital) emergency room to inform facility that resident (R1) admitted to hospital with [DIAGNOSES REDACTED]. On 1/28/15 at 9:23 AM, Z7 (R1's Primary Care Physician), stated he had not been notified of R1's change in condition, elevation in temperature, reports of not him not feeling well nor of low SPO2. Z7 stated he was aware R1 returned to the hospital but thought it was related to his "Kidney Growth." Z1 stated he would not have expected R1 to pass away "at this time," and added that he had not been made aware R1 had passed. Z7 said it is his expectation that any change in conditions be reported to him, particularly those involving a decline. 2. R2 was admitted to the facility on [DATE] according to the Face Sheet, as a Medicare resident. The medical record contained no head to toe nursing assessment on R2 until 1/24/15 at 3:51 AM. At that time, her right lower extremity was found to have a "right calf bruise," dark in color, "from mid point to ankle and appears black. There are multiple scattered fluid filled blisters. The right inner ankle has a reddened area that is warm to touch and painful. It measures 8.5 (cm) X 6.5 (cm). The skin has pitted in several areas and is open to those areas." On 1/28/15 at 9:07 AM, E14 (CNA) stated he had worked with R2 on Sunday (1/18/15) at which time R2 "told me her leg was sore. I looked at it and I saw bruising and some discoloration." E14 said "I don't recall if I reported it to the nurse, but R2 did tell me she had already told the nurses." E14 said he did not work with R2 again until 1/23/14 (10:00 PM) to 1/24/14 (6:00 AM). E14 said he responded to R2's call light to assist her to the bathroom. E14 said as he touched her legs to help her up, she "yelped." E14 said he looked at her right lower leg and asked her what happened. E14 said R2 told him "Physical Therapy had been putting green (cold/hot) gel on it." E14 described R2's right lower leg as discolored, dark bruise at the calf with redness down to her ankle that was "hot to touch." E14 said there was a "split" in her skin near the right medial ankle. E14 said, "(R2) told me she had been telling everyone who has been caring for her since Monday, (1/19/15) about the pain and burning concerns with her right lower leg." On 1/27/15 at 2:01 PM, E13 stated she was the nurse for R2 on the night shift 10:00 PM(1/23/15) to 6:00 AM (1/24/15). E13 stated she gave R2 pain medication, (documented in the notes as given at 11:43 PM on 1/23/15), and "about 1 to 1.5 hours later, E14 came to me" expressing concern that R2 had a bruise behind her right lower extremity and it was blackened from the knee to ankle. R2's heel was red and warm." E13 said the bruised area was dark purple, "almost blackish." E13 said she assessed the right lower leg "between 12:30 and 1:30 AM." E13 stated, "Because the Specialists (Orthopedic MD's) don't call back Nursing Homes at night, I just waited to call until 5:30 AM when I knew they would be making rounds at the hospital." The nursing note of 1/24/15 at 6:12 AM, showed a return call was received from an on call orthopedic physician and an order was given to call 911 and send R2 to the local hospital. The nursing note of 1/24/15 at 3:51 AM reads, "complaint of right low leg pain." The only right leg assessment documentation was written on 1/24/15 at 5:44 AM. The 1/24/15 note reads as follows: "(R2) in room with C/O (complaints of) severe right low leg pain. Right leg assessed. Knee incision is well approximated. There is no sign of infection. Right calf bruise has darkened from mid point to ankle and appears black. There are multiple scattered fluid filled blisters. The right inner ankle has a reddened area that is warm to touch and painful. It measures 8.5 (cm) X 6.5 (cm). The skin has pitted in several areas and is open in those areas. MD (Z6 - Orthopedic Surgeon) paged at this time. (Z6) is currently at (local hospital). Awaiting return call at this time." The progress notes identified R2 had a change in location and intensity of pain status on 1/19/15 with no assessment completed until 1/24/15 between 12:30 AM and 1:30 AM. (More than 4 days later). The physician was not notified until 1/24/15 at 5:44 AM, (more than 4 days after a change in pain was reported and more than 4 hours after the changes in R2's leg condition was identified.) On 1/29/15 at 4:45 PM, Z6 stated R2 was admitted to the hospital with [REDACTED]. The earlier treatment would have prevented some of the pain R2 experienced. Z6 stated it is his understanding the facility applied a topical [MEDICATION NAME] which actually caused R2 more pain. Z6 said earlier detection also would have shortened R2's hospital stay. Z2 said he would have expected the facility to call and notify him of the complaints being expressed by R2. Z6 stated physicians should be notified "earlier rather than later," as complaints or changes occur. On 1/27/15 at 3:30 PM, (at the local hospital), R2's right lower extremity was propped on a pillow with some dried yellow drainage on the pillowcase. R2 explained the drainage was a result of "the blisters popping." R2's right lower leg was red, purple and dark in color from the top of calf extending down to to her ankle. The right medial ankle area was bright red in color extending between the anterior portion of the foot to the plantar area. The discoloration was outlined in purple marker to monitor the extent of the infected tissue. The facility policy titled, Change in a Resident's Condition or Status, Revised 11/2013, states: "Our facility shall promptly notify the resident, his or her Attending Physician and representative (sponsor) of changes in a resident's medical/mental condition and/or status..." Some of the factors listed in the policy are, "[MEDICAL CONDITION] joint disease, [MEDICAL CONDITION] arthritis, Pressure, venous or arterial ulcers, surgical incision, [MEDICAL CONDITION] ([MEDICAL CONDITION], [MEDICAL CONDITION]" and "Pneumonia." The policy states the staff are to document the resident's reported level of pain with adequate detail," and report to the physician or practitioner, "significant changes in the level of the resident's pain." The policy defines a "significant change" as, "a decline or improvement to the residents status that...will not normally resolve itself without intervention." The policy also has written, "Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status...Nurse will record the resident's medical record information relative to changes" in the residents condition. The facility policy titled, Acute Condition Changes - Clinical Protocol, Revised 11/2013 shows, "someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician."

Based on interview and record review, the facility neglected to follow their policies for , Acute Condition Changes, Pain Management, and Documentation. These failures contributed to a resident (R1), experiencing a 30 hour delay in assessment of his complaints of not feeling well. R1 was admitted to a local hospital with pneumonia, an elevated temperature and low blood oxygen concentration of 75%. R2 experienced increased unresolved pain for more than 4 days and developed a blackened right lower extremity. R2 was hospitalized to treat [MEDICAL CONDITION] and was given IV (intravenous) Antibiotic treatment. This applies to 2 of 3 residents (R1 & R2) reviewed for acute changes in condition in the sample of 9. The findings include: 1. R1's hospital discharge notes dated 12/27/14 showed a written order to specifically notify the physician, "If the patient has any sudden shortness of breath or sudden weight gain." The facility's document titled, Residents at Risk for Readmission Assessment, dated 12/29/14 identified R1 having a history of Pneumonia. On 1/27/15 at 10:11 AM, E9 (Restorative CNA) stated, on 1/24/15, (Saturday), she observed R1's call light on and went to assist him. E9 said R1 told her he "didn't feel right and that his left arm felt prickly." E9 said he "just didn't look right." E9 said she reported R1's concerns to E6 (Registered Nurse - RN). At 12:41PM, E6 RN) stated R1 complained of "feeling weaker" on Saturday and was "running a low grade temp (temperature) of about 99 degrees Fahrenheit." at 11:55 AM, E4 (Licensed Practical Nurse - LPN) stated E6 reported R1 "was not feeling well and was running a low grade temp (temperature) so he stayed in his room most of the day." E4 said he went to R1's room to check his vital signs and obtained an SPO2 (blood oxygen saturation reading) of 75%. (Normal values 95-100%). E4 said the Oxygen was applied at 2L via nasal cannula with no change in saturation. E4 said he then "bumped it up to 3L" and obtained an SPO2 reading of 80%. On 1/28/15 at 9:23 AM, Z7 (R1's Primary Care Physician), stated he had not been notified of R1's change in condition, elevation in temperature, reports of not him not feeling well or of the low SPO2. Z7 stated he was aware R1 returned to the hospital but thought it was related to Kidney issues. Z1 stated he would not have expected R1 to pass away "at this time," and added that he had not been made aware R1 had passed. Z7 said it is his expectation that any change in conditions be reported to him, particularly those involving a decline. None of the findings or concerns was included in R1's clinical record. The documentation showed R1 was assessed on 1/24/15 at 10:46 AM, but not again until 1/25/15 between 6:30 PM to 7:00 PM, after R1's family called 911.A nursing entry made by E12 on 1/25/15 at 9:35 PM showed the facility was informed that resident (R1) admitted to hospital with [DIAGNOSES REDACTED]. During an interview with E6 (RN) and E13 (LPN) on 1/27/15 at 12:41 PM and 2:01 PM consecutively, stated Medicare Residents are to have focused assessments every shift, with complete head to toe assessment done daily. The assessments are to be documented in the medical record. The facility policy titled, Change in a Resident's Condition or Status, Revised 11/2013, defines a "significant change" as, "a decline or improvement to the residents status that...will not normally resolve itself without intervention." Examples of changes that should be reported to the physician including, "A significant change in the resident's physical/medical/mental condition; A need to transfer the resident to a hospital/treatment center; Instructions to notify the physician of changes in the resident's condition." The policy includes, "Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status...Nurse will record the resident's medical record information relative to changes" in the resident ' s condition. 2. R2 was admitted to the facility on [DATE] according to the Face Sheet, as a Medicare resident. The medical record contained no head to toe nursing assessment on R2 until 1/24/15 at 3:51 AM. At that time, her right lower extremity was found to have a "right calf bruise," dark in color, "from mid point to ankle and appears black. There are multiple scattered fluid filled blisters. The right inner ankle has a reddened area that is warm to touch and painful. It measures 8.5 (cm) X 6.5 (cm). The skin has pitted in several areas and is open to those areas." On 1/27/14 at 3:30 PM, R2 stated she experienced right lower leg pain for over 4 days after her admission to the facility. R2 said staff only checked the surgical incision sight on her right knee but did not assess her right lower leg where the pain was occurring. R2 described her skin as being hot to the touch and felt as if her skin was burning. R2 had severe pain with movement or slight touch. R2 said she reported it to all staff that provided care to her during her one week stay at the facility. R2 said Z5 (Physical Therapy Aide) began applying ice packs and attempted ice massage to her right lower leg on 1/20/15 - 1/21/15. R2 stated she was concerned because her leg kept getting "hotter and hotter." On 1/27/15 at 2:01 PM, E13 (LPN) stated on 1/24/15, between 12:30 and 1:30 AM, E14 reported a concern with R2's right lower leg. E13 said the right lower leg had a bruised area, dark purple, "almost blackish" in color. E13 said, "Because the Specialists (Orthopedic MD's) don't call back Nursing Homes at night, I just waited to call until 5:30 AM when I knew they would be making rounds at the hospital." On 1/28/15 at 9:07 AM, E14 (CNA) stated he had worked with R2 on Sunday (1/18/15) at which time R2 "told me her leg was sore. I looked at it and I saw bruising and some discoloration." E14 said, on 1/24/15, while assisting R2, he touched her legs to help her up, she "yelped." E14 said he looked at her right lower leg and described it as discolored, dark bruise at the calf with redness down to her ankle that was "hot to touch." E14 said there was a "split" in her skin near the right medial ankle. E14 said, "(R2) told me she had been telling everyone who has been caring for her since Monday, (1/19/15) about the pain and burning concerns with her right lower leg." The nursing notes of 1/19, 1/20 and 1/21 describe R2 complaining of, "right leg pain," on 1/19/15 at 10:55 PM and 1/20/15 at 2:35 PM. On 1/21/15 at 5:49 AM and 11:46 AM, the notes showed R2 was complaining of "burning/aches: legs hurt." Nursing notes of 1/22/15 at 4:00 PM and 7:28 PM showed R2 was complaining of "restless legs/leg spasms." Another entry dated 1/24/15 at 3:51 AM, described R2 as complaining of "severe right low leg pain. On 1/29/15 at 4:45 PM, Z6 (orthopedist) stated R2 was admitted to the hospital with [REDACTED]. The earlier treatment would have prevented some of the pain R2 experienced. Z6 stated it is his understanding the facility applied a topical [MEDICATION NAME] which actually caused R2 more pain. Z6 said earlier detection also would have shortened R2's hospital stay. Z2 said he would have expected the facility to call and notify him of the complaints being expressed by R2. Z6 stated physicians should be notified "earlier rather than later," as complaints or changes occur. The facility policy titled Pain Screening and Management, Revised 11/2013, states , "Pain management" is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident. Staff is to "effectively recognize the presence of pain; identify the characteristics of pain; addressing the underlying causes of pain...and monitor the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain." Staff are to "identify conditions or situations that may predispose the resident to pain including," [MEDICAL CONDITION] Joint Disease, [MEDICAL CONDITION] Arthritis, Pressure, Venous or Arterial ulcers, surgical incisions, [MEDICAL CONDITION] and Pneumonia.

Based on observation, interview and record review, the facility failed to provide nursing services by not monitoring and responding to two residents with condition changes related to pain and breathing difficulty. This failure contributed to the demise of R1 and the hospitalization of R2. This applies to 2 residents (R1 & R2) of 3 residents reviewed for nursing care in the sample of 9. The findings include: 1. The facility face sheet dated 1/17/15 showed R2 was admitted to the facility on [DATE] for aftercare following a scheduled knee replacement surgery. On 1/27/15 at 3:30 PM, R2 was interviewed. R2 was alert, oriented, cooperative and able to express her experiences in detail. R2's right lower extremity was propped on a pillow with some dried yellow drainage on the pillowcase. R2 explained the drainage was a result of "the blisters popping." R2's right lower leg was red, purple and dark in color from the top of calf extending down to to her ankle. The right medial ankle area was bright red in color extending between the anterior portion of the foot to the plantar area. The discoloration was outlined in purple marker to monitor the extent of the infected tissue. R2 continued explaining she had a total right knee replacement surgery on 1/13/15. R2 stated her Orthopedic Physician (Z8) felt she needed "a little more therapy," before returning home. R2 agreed to placement in a local facility for rehabilitation purposes. R2 stated after about 2-3 days in the facility, she began experiencing right lower leg pain and "burning." R2 said her right leg was getting "hotter and hotter on the flesh as the days went by." R2 stated she told all the Certified Nursing Assistants (CNA's) and nurses who provided cares, of her concerns. R2 stated the staff would come in and change the dressing to her incision site at the knee but never looked at her lower leg. R2 stated, on "Monday or Tuesday," (1/19/15 or 1/20/15) she told the "physical therapy guy named (Z5 - Physical Therapy Aide - PTA), about it." R2 said Z2 did express concern that it was getting "hotter and hotter" so he began applying ice packs. The ice packs really didn't help so he (Z5) put a green cold/hot type gel all over my leg and massaged it. It burned and made it worse, so he wiped it off with a towel and started applying ice again. R2 stated she began to get very concerned because she hadn't heard from her physician yet and "I wasn't sure what was going on." During a shower, one of the staff "rubbed a mint lotion on it (lower right leg) because it hurt so bad. She had to be very gentle because I yelped if anyone touched it." R2 said Z5 and the nurse (unable to recall the nurses name) who changed her dressings the 3 consecutive nights prior to her current hospitalization (1/24/15), "told me my pain was normal after this type of surgery. The nurse never looked at my lower leg. Only the incision at the knee." (There is no documentation of the dressing changes.) R2 said at about 1:00 AM on 1/24/15, E14 (CNA) responded to her call light to assist her to the bathroom. R2 said when E14 was helping her up she "yelped when he touched my leg." R2 said E14 turned on the lights in the room to look at R2's right lower extremity. R2 said E14 was "shocked and asked me what happened." R2 said E14 had cared for her when she first arrived but had been off for about 4 days. R2 said E14 knew what it looked like when I came in and what it looked like now (1/24/15)." R2 said E14 went to get the nurse E13 (Licensed Practical Nurse-LPN) to assess her leg. R2 said E13 was very upset and said she would call Z6 (Orthopedic Physician). R2 said, "I told anyone that came in my leg was burning, blistering and hot. Apparently no one told anyone." R2 said when the facility "propped her leg" they used a paper covered pillow with fabric pilling which added to the discomfort." R2 said they "would not put a fabric pillow case on it (pillow)." R2 stated she was in tears when she arrived to the local hospital emergency room because "I finally felt safe! I felt like I was in danger of losing my leg and no one would listen to me." R2 said, thinking back on it, "I guess I should have just called 911 myself." On 1/27/15 at 2:01 PM, E13 stated she was the nurse for R2 on the night shift 10:00 PM(1/23/15) to 6:00 AM (1/24/15). E13 said on 1/23/14 at (10:00 PM) report, she was told that a muscle relaxant had been added to R2's medication regimen due to "leg pain." E13 said when R2 began to complain of leg pain, it was "described by R2 and appeared to be muscle issues so Requip was ordered for Restless Leg Syndrome and a muscle relaxer." E13 stated focused assessments are done on every shift and head to toe physical assessments are completed daily on Medicare Residents. E13 stated the head to toe assessments are to be divided and completed on the first and second shifts. E13 stated no assessments are assigned to the 3rd shift in an effort to maximize residents sleeping routine. E13 stated she gave R2 pain medication, (documented in the notes as given at 11:43 PM on 1/23/15), and "about 1 to 1.5 hours later, E14 came to me" expressing concern that R2 had a bruise behind her right lower extremity and it was blackened from the knee to ankle. R2's heel was red and warm." E13 said the bruised area was dark purple, "almost blackish." E13 said she assessed the right lower leg "between 12:30 and 1:30 AM." E13 stated, "Because the Specialists (Orthopedic MD's) don't call back Nursing Homes at night, I just waited to call until 5:30 AM when I knew they would be making rounds at the hospital." E13 said the Orthopedic on call returned her call quickly and ordered R2 to be sent to the local hospital. On 1/27/15 at 12:10 PM, Z5 (PTA) said R2 had problems with swelling and pain in her knee. Z5 said he began icing her leg once a day on Tuesday (1/20/15) or Wednesday (1/21/15). Z5 stated the icing didn't seem to be providing enough relief so he tried "ice massage," (using the cold/hot gel.) Z5 said R2 did not tolerate the ice massage "at all" telling him that it burned her skin. Z5 said he explained the gel needed about 10 minutes to "freeze" her leg and that the burning would stop. Z5 said she refused so he went back to using crushed ice packs twice a day. Z5 said R2's right lower extremity was warm to the touch so "that is why I used ice." Z5 said, it is his opinion that "we (facility)" should try more to utilize other treatment modalities to relieve pain instead of medicaion. Z5 said, "I didn't think R2's pain or swelling was any more than other total knee replacement residents I have worked with. Sometimes they just have to work through it." When asked if he reported or documented his treatments, Z5 said he works closely with E11 (Registered Nurse-RN) and made her aware. On 1/27/15 at 12:52 PM, E11 (RN) stated Z5 had never reported any concerns or complaints verbalized by R2. On 1/28/15 at 7:50 AM, Z2 (Physical Therapist) stated before using the green cold/hot gel, "an order should be obtained by a physician because of possible allergies [REDACTED]." Z2 stated ice therapy can be used to decrease [MEDICAL CONDITION] after a therapy treatment but the green cold/hot gel is used for pain managment. Z2 said these two treatments should not be used together. On 1/28/15 at 9:07 AM, E14 (CNA) stated he was the CNA who identified the concerns with R2's leg on 1/24/15. E14 stated he had worked with R2 on Sunday (1/18/15) at which time R2 "told me her leg was sore. I looked at it and I saw bruising and some discoloration." E14 said "I don't recall if I reported it to the nurse, but R2 did tell me she had already told the nurses." E14 said he was off for several days and did not work with R2 again until 1/23/14 (10:00 PM) to 1/24/14 (6:00 AM). E14 said he responded to R2's call light to assist her to the bathroom. E14 said as he touched her legs to help her up, she "yelped." E14 said he looked at her right lower leg and asked her what happened. E14 said R2 told him "Physical Therapy had been putting green (cold/hot) gel on it." E14 described R2's right lower leg as discolored, dark bruise at the calf with redness down to her ankle that was "hot to touch." E14 said there was a "split" in her skin near the right medial ankle. E14 said, "(R2) told me she had been telling everyone who has been caring for her since Monday, (1/19/15) about the pain and burning concerns with her right lower leg." The nursing notes dated 1/19/15 at 10:55 PM and 1/20/15 at 2:35 AM, showed R2 complained of "Right Leg" pain (not knee pain as was documented prior.) On 1/21/15 at 5:29 AM and 1/21/15 at 11:46 AM, the nursing notes showed R2 complained of "burning/aches: legs hurt." The nursing notes have no documentation of an assessment of R2's leg/legs. On 1/21/15 at 8:35 PM, a nursing note entry showed Requip, (a medication used for Restless Leg Syndrome), had been ordered and given. On 1/22/15 at 4:00 PM and 7:28 PM, the progress notes showed R2 complained of "restless legs/leg spasms." On 1/23/15 at 8:00 PM and 11:43 PM, the nursing notes again showed R2 was complaining of "leg pain." The nursing note of 1/24/15 at 3:51 AM reads, "complaint of right low leg pain." The only right leg assessment documentation was written on 1/24/15 at 5:44 AM. The 1/24/15 note reads as follows: "(R2) in room with C/O (complaints of) severe right low leg pain. Right leg assessed. Knee incision is well approximated. There is no sign of infection. Right calf bruise has darkened from mid point to ankle and appears black. There are multiple scattered fluid filled blisters. The right inner ankle has a reddened area that is warm to touch and painful. It measures 8.5 (cm) X 6.5 (cm). The skin has pitted in several areas and is open in those areas. MD (Z6 Orthopedic Surgeon) paged at this time. (Z6) is currently at (local hospital). Awaiting return call at this time." The nursing note of 1/24/15 at 6:12 AM showed a return call was received from a physician and an order was given to call 911 and send R2 to the local hospital. The call was placed more than 4 hours after the identification of R2's "blackish" leg. On 1/29/15 at 4:45 PM, Z6 stated R2 was admitted to the hospital with [REDACTED]. The earlier treatment would have prevented some of the pain R2 experienced. Z6 stated it is his understanding the facility applied a topical [MEDICATION NAME] which actually caused R2 more pain. Z6 said earlier detection also would have shortened R2's hospital stay. Z2 said he would have expected the facility to call and notify him of the complaints being expressed by R2. Z6 stated physicians should be notified "earlier rather than later," as complaints or changes occur. 2. R1 is a [AGE] year old resident with a full code status according to the Advance Directive sheet dated 12/27/14. The facility face sheet dated 12/27/14 lists R1's [DIAGNOSES REDACTED]. Z9 stated R1 was falling while at home and having difficulty getting around. Z9 said R1 went to the hospital after his last fall and then was admitted to the facility with weakness after his hospitalization . On 1/27/15 at 8:00 AM, E3 (Assistant Director of Nursing-ADON) stated she was aware that E4 (LPN) received a phone call on 1/25/15 (Sunday) from Z10. Z10 called E4 to tell him that she (Z10) had just talked to R1 on the phone. R1 told Z10 he wasn't feeling good and that facility staff told him (R1) they would not send him to the hospital. E3 stated Z10 called 911 for R1 and the ambulance arrived before E4 could finish an assessment on R1. E3 stated, "(R1) was admitted to the hospital with [REDACTED]." On 1/27/15 at 10:11 AM, E9 (Restorative CNA) stated she had worked the weekend (1/24/15 and 1/25/15) with R1. E9 stated on 1/24/15, (Saturday), she observed R1's call light on and went to assist him. E9 said R1 told her he "didn't feel right and that his left arm felt prickly." E9 said he "just didn't look right." E9 said she reported R1's expressed concerns to E6 (Registered Nurse - RN). E9 said E6 went to check on him. On 1/27/15 at 12:41 PM, E6 (RN) stated she worked with R1 on Saturday (1/24/15) and Sunday (1/25/15) on the day shift. E6 stated R1 complained of "feeling weaker" on Saturday and was "running a low grade temp (temperature) of about 99 degrees Fahrenheit." (Elevated temperature not documented.) E6 stated she asked Z2 (Physical Therapist) to check his extremities. E6 said, "He (R1) was a complainer" and would state "no one would do anything" for him. E6 stated Medicare residents are to be charted on every shift. On 1/27/15 at 10:53 AM, Z2 stated he was asked by E6 to check on R1, (Saturday 1/24/15), as he (R1) was complaining of feeling weak. Z2 said, "I checked the strength in (R1's) extremities and found no decline. E6 then told me (Z2) that R1 was running a temperature. Z2 said, "I thought maybe that was why he was feeling weak." Z2 stated that R1 had complained during therapy of being easily tired. On 1/27/15 at 11:55 AM, E4 (LPN) stated he received report for the PM shift on 1/25/15 from E6 (RN). E4 said E6 reported R1 "was not feeling well and was running a low grade temp (temperature) so he stayed in his room most of the day." E4 said he went and checked R1's vital signs, but did not chart them "because they were normal." E4 said between 6:30 PM and 7:00 PM, Z10 called and told him R1 was "short of breath (SOB) and weak" and she (Z10) wanted him to go to the hospital. E4 said he went to R1's room to check his vital signs and obtained an SPO2 (blood oxygen saturation reading) of 75%. (Normal values 95-100%). E4 said E12 (LPN) was with him in R1's room and left to obtain oxygen. E4 said the Oxygen was applied at 2L via nasal cannula with no change in saturation. E4 said he then "bumped it up to 3L" and obtained an SPO2 reading of 80%. E4 said, "at about that time the EMT's (Emergency Medical Technician's) arrived." E4 said "The ambulance personnel told me (Z10) called 911." E4 said he did not observe any physical signs of distress other than "an increased respiratory rate." E4 did not document R1's vital signs. E4 stated if a resident is "critical" then he would call 911, otherwise he would notify the resident's physician of a change in condition. On 1/28/15 at 9:23 AM, Z7 (R1's Primary Care Physician), stated he had not been notified of R1's change in condition, elevation in temperature, reports of not him not feeling well nor of low SPO2. Z7 stated he was aware R1 returned to the hospital but thought it was related to his Kidney Growth. Z7 explained, R1 was having numerous falls at home and was taken to the local hospital. Z1 stated he would not have expected R1 to pass away "at this time," and added that he had not been made aware R1 had passed. Z7 said it is his expectation that any change in conditions be reported to him, particularly those involving a decline. A nursing note dated 1/23/15 at 6:49 PM showed R1 was exhibiting some mood swings through out the day. On 1/24/15 at 10:46 AM, the nursing note showed R1 was having some nasal drainage. There were no nursing entries into the progress notes for 1/24/15 and 1/25/15, addressing R1's complaints of not feeling well, prickly left arm or elevated temperature. A nursing note entry dated 1/25/15 at 7:00 PM documents R1's decline as follows: "This nurse received phone call from (Z10) about (R1) informing me (E4) resident isn't feeling well. Assured (Z10) that I (E4) would go in and assess him (R1). Obtained V/S (vital signs). Unit A Nurse (E12 LPN) obtained O2 sat (saturation) of 75% on room air. Applied O2 at 2L/min per standing order. Lung sounds clear, diminished and breathing at a rate of 24 BPM (beats per minute). O2 sats up to 80% at 3L/min. Then at 6:50 PM EMT's arrived at room. Asked who called them because I (E4) had not made a phone call yet to MD to report change of condition, was informed that (Z10) had called them. EMT's left with resident (R1) at approximately 7:00 PM to transfer to (local hospital). Called (local hospital) to give nurse to nurse report, faxed over transfer sheet. Called MD. (Z12) returned phone call and was informed of situation and order received, see POS (physician order [REDACTED]." A nursing entry made by E12 (LPN) on 1/25/15 at 9:35 PM showed, "received phone call from (local hospital) emergency room to inform facility that resident (R1) admitted to hospital with [DIAGNOSES REDACTED]. A nursing entry dated 1/26/15 at 3:58 PM, written by E3 (ADON) showed Z11 called to question R1's care as he was currently in the CCU (critical care unit) on Bi-Pap (positive pressure airway ventilation to assist breathing.) The documentation shows R1 had told his family that the facility told him they would not send him to the hospital. E3 documented she explained the facility protocol to Z11. The facility policy titled, Pain Screening and Management, Revised 11/2013, defines pain management as alleviating the pain to "a level that is acceptable to the resident." The policy states the pain management process involves, "effectively recognizing there presence of pain; identifying the characteristics of pain; and addressing the underlying causes of the pain." The policy shows staff are to attempt to identify the cause of the pain and "conditions or situations that may predispose" the resident to problems. The staff are to "monitor the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain." The facility policy titled, Change in a Resident's Condition or Status, Revised 11/2013, gives examples of changes that should be reported to the physician include, "A significant change in the resident's physical/medical/mental condition; A need to transfer the resident to a hospital/treatment center; Instructions to notify the physician of changes in the resident's condition." The policy defines a "significant change" as, "a decline or improvement to the residents status that...will not normally resolve itself without intervention." The policy also has written, "Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status...Nurse will record the resident's medical record information relative to changes" in the residents condition. The facility policy titled, Acute Condition Changes - Clinical Protocol, Revised 11/2013 shows, "someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician."

Based on observation, interview and record review the facility failed to ensure pressure relieving devices, ordered barrier cream was used, and failed to monitor a resident's skin condition and obtain orders for a new pressure area to prevent skin breakdown. The facility failed to reduce friction for a resident during transfers. These failures resulted in a resident (R41) acquiring a Stage IV pressure ulcer. This applies to 3 of 5 residents (R41, R36, R35) reviewed for pressure ulcers in the sample of 17. The findings include: 1. R41 was admitted to the facility on [DATE] according to the 9/10/13 Minimum Data Set.. The admission nursing assessment completed on 9/10/13, performed by the facility nurse shows R41 to have no history of pressure ulcers and no current pressure ulcers. The Head to Toe body diagram of 9/10/13 shows R41's buttock area to be chaffing and scaling. The 9/10/13 Braden Scale for predicting pressure sores risk score was 12, indicating R41 was at a high risk for pressure ulcers. The 9/17/13 admission MDS (Minimum Data Set) documents R41 required extensive assistance with a 2 person physical assist for bed mobility and transferring from a bed to a chair. On 9/10/13, the wound nurse documented R41 was admitted with red, dry flaky skin to buttock and over the counter creams were being applied. The 9/10/13 care plan for R41 shows a risk for skin breakdown due to immobility and incontinence (of bowel). The care plan interventions listed for R41 include review for skin breakdown, reposition every 2 hours, keep skin clean and dry, monitor placement of urinary drainage tubing, provide protective devices, skin check daily, and to use dimethicone wipes. On 4/24/14 at 9:15 AM, E9 CNA (Certified Nursing Assistant) stated R41 is never up out of bed for more than 1 hour at a time because of her pressure sore on her bottom. E9 stated she is turned every 2 hours on her sides, never onto her back. E9 said R41 is only up for meals. E9 stated there is no where to document when R41 is turned and on which side. E9 said a verbal report is given to the next shift and a walk through the hallway is done to check on each resident in bed. On 4/24/14 at 12:40 PM, E2 DON (Director of Nurses) stated there is no documentation for residents requiring turning. E2 stated the turns are done on the even hours. E2 stated " It is just a nursing thing, it is what you do. You turn people every 2 hours. I work the floor and see the aides do their rounds every even hour." On 9/17/13, the wound care nurse documented R41 had no improvement and treatment is to continue. On 9/24/13 the wound nurse documented the buttock area remains excoriated, no changes are made at this time. On 9/27/13, the wound nurse documented Calazyme order in place and areas of necrotic tissue (black, brown or tan tissue that adheres firmly to the wound bed) were noted. On 10/1/13 (4 days later) the wound nurse noted the wound is covered with necrotic tissue and measures 8 cm x 2.5 cm. On 4/23/14 at 11:20 AM, E4 Wound Nurse was observed measuring the wound. The wound measures 3.7 cm x 2.2 cm and 2.8 cm in depth and is a Stage IV pressure ulcer. The wound appears red, no drainage or odor noted. The wound is tunneling out at 3 different areas. On 4/24/14 at 11:15 AM, E4 said she would have approached R41's wound in a different manner right from admission. E4 stated she would have notified the physician and obtained an order for [REDACTED]. E4 stated that if a wound has shown no improvement after 2 weeks of the same treatment, then the physician is to be notified and a new order is obtained. On 10/25/13 and 12/21/13, R41's primary physician documented visits and made no documentation regarding the wound. The physician progress notes [REDACTED]. 2. R36's MDS of 2/11/14 shows [DIAGNOSES REDACTED]. The 2/11/14 MDS shows R36 has an abdominal feeding tube, and requires extensive assistance from staff with bed mobility, transfers, dressing, eating, and personal hygiene. This MDS also shows R36 has severe cognitive impairment, difficulty focusing attention, disorganized thinking, and unclear speech. R36's "Braden Scale - For Predicting Pressure Sore Risk" dated 2/11/14 shows R36 had a score of 15 (Total Score of 12 or less represents high risk). This assessment shows that R36's skin is "Rarely Moist-Skin is usually dry". R36's "Pressure Sore/Wound Admission and Weekly Flow Sheet" shows R36 had a Stage II pressure ulcer develop on 1/12/14 to her left upper buttock and another Stage II Pressure Ulcer develop on 1/23/14 to her "L (left) Buttock". On 4/22/14 at 12:05 PM, E6(CNA) and E7 (CNA) transferred R36 to the toilet with a stand lift. E6 and E7 provided incontinence care to R36 after transferring her to the bed. R36 had a red dime-sized area to her left buttock. E6 said R36 "has an open area on her buttock that we put cream on". On 4/24/14 at 10:30 AM, E4 (RN-Wound Care Nurse) said she was not aware that R36 had a pressure ulcer to her bottom. E4 said when the nurses find a pressure ulcer or area of concern they report it to her, she assesses it, and chooses appropriate interventions. On 4/24/14 at 11:00 AM, E6 said R36 had a spot on her bottom that is "kind of red and open". E6 said she reported it to the nurse the day before. R36 record has no nursing documentation that R36 had a pressure sore to her left buttock documented on 4/22/14 or 4/23/14. R36's hospital nursing documentation dated 4/23/14 shows R36 was admitted to the hospital with [REDACTED]. The facility had no documentation of the pressure sore prior to R36's discharge to the hospital. 3. R35's Physician order [REDACTED]. The MDS of 3/25/14 shows R35 is cognitively intact and requires extensive assistance from staff with transfers, changing position in bed, dressing, toilet use, and personal hygiene. The 3/25/14 MDS shows R35 does not have an "unhealed pressure ulcer stage 1 or higher". On 4/23/14 at 2:00 PM, R35 said she had a small area under her abdominal fold that the nurses were treating. R35 lifted the abdominal fold to show an approximately one inch red slit along her abdominal fold. The surrounding tissue was red and moist. R35's admission skin assessment dated [DATE] does not show any areas of concern for her abdominal or groin area. R35's Skin assessment dated [DATE] shows R35 was not at high risk for developing a pressure sore with a score of 17 (score of 12 or less represents high risk). R35's Nurse's Notes Wound assessment documentation dated 3/12/14 shows "Abd (abdomen) and peri-area and left upper thighs are less red. no open areas noted..." On 4/24/14 at 1:25 PM, E5 (Licensed Practical Nurse-LPN) said R35 has a small open area along her abdominal crease that the nurses are applying cream to. E5 said she does the treatment once a shift but does not complete the wound assessment. E5 said the wound care nurse does the weekly assessments on the pressure ulcers, not the treatment nurse. E5 said she would consider this a Stage II pressure ulcer because the skin is open. On 4/24/14 at 1:35 PM, E4 (wound nurse) said R35 does not have any pressure ulcers or open areas. E4 said R35 has a healed area to her coccyx that she does weekly assessments on, but she does not have any current pressures sores or open areas. R35's Pressure Sore Weekly Flow Sheet shows R35 developed a Stage II Pressure Sore to her Coccyx on 3/12/14. The same assessment shows R35's pressure sore reopened on 4/3/14. R35's 4/10/14 weekly assessment shows "wound bed is closed but will continue treatment as skin is fragile and gets stretched when she uses slide board to transfer". On 4/24/14 at 10:30 AM, E4 (wound nurse) said R35 got the pressure sore because her skin stretched and caused a slit to her coccyx. E4 said the area healed and then reopened not long after. E4 said R35 still uses the slide board to transfer from her bed to her chair and from her chair to the bed. R35's skin breakdown/pressure ulcer care plans do not include any interventions to prevent the slit from reoccurring during the slide board transfers. R35's care plan does not include any interventions for other methods of transfer. The 8/11 facility policy "Pressure Ulcer Prevention/Skin Care states "If the resident has any pressure ulcers, vascular ulcers, or diabetic ulcers, the documentation will be completed on the Pressure Ulcer and Wound Admission and Weekly Flow Sheet." "Individualize Plan of Care for resident when pressure ulcer is present." "PUSH tool will be completed for all pressure ulcers on a weekly basis." The 8/11 facility policy "Pressure Ulcer Potential Screening" states "5. If score is 15-18, resident is considered mild risk." "6. If score is 13-14, the resident is considered moderate risk." "7. If score is 10-12, the resident is considered high risk". "Documentation - Description of all existing pressure ulcers will be done on a weekly basis and will include the following documentation per individual site: Stages according to the NPUAP, Size in centimeters, Depth in centimeters, Color of Wound, Drainage, Location of necrotic tissue, Condition of wound margins, Any undermining or tunneling."

Based on observation, interview, and record review the facility failed to ensure a resident was monitored during transport out of the facility while a tube feeding was infusing. The facility also failed to ensure the nursing staff was notified when the resident returned to the facility. This failure resulted in R36 receiving a 900 ml enteral (tube) feeding bolus causing the resident to vomit for 14 hours. This applies to 1 of 1 residents (R36) reviewed for Gastric Tubes in the sample of 17. The findings include: R36's MDS of 2/11/14 shows [DIAGNOSES REDACTED]. The 2/11/14 MDS shows R36 has an abdominal feeding tube, and requires extensive assistance from staff with bed mobility, transfers, dressing, eating, and personal hygiene. This MDS also shows R36 has severe cognitive impairment, difficulty focusing attention, disorganized thinking, and unclear speech. On 4/22/14 at 11:00 AM, R36 was sitting in a wheelchair in the sitting room located on the 300 hall. R36 had a neck brace on, and an enteral feeding infusing to gravity. R36's enteral feeding and enteral feeding pump were attached to a pole on her wheelchair. The pump was turned off, and the enteral feeding tubing was outside of the pump chamber and free flowing to gravity. R36's enteral feeding bag was dated 4/22/14 and the label stated the bag was hung at 9:50 AM. On 4/22/14 at 12:05 PM, E7 (Certified Nurse Assistant- CNA) wheeled R36 out of the dining room. R36 had vomited a large amount of pale, milky, white, tube-feeding substance on her neck brace, down the front of her shirt, and saturating through her pants. R36 continued to cough as she was wheeled down the hallway. E7 said he was sitting next to R36 in the dining room, and she (R36) attempted to take a drink and started "profusely throwing up". R36's enteral feeding was then infusing through the pump at a rate of 50ml per hour. There was approximately 500mls remaining in the bag. On 4/22/14 at 12:05 PM, E8 (Registered Nurse - RN) said she hung R36's bag of enteral feeding at 9:50 AM. E8 said she put 1500ml in the bag and the pump was to infuse 50 ml's per hour. E8 looked at the hanging feeding bag and said "there is only 500 ml's left". E8 said R36 should have only had "about 100mls since the bag was hung, and instead she got 1000mls (900 mls more than ordered in a two hour time frame)". E8 said R36's feeding is supposed to be infused by a pump, not to gravity. E8 said she sent R36 out of the facility to the hospital for a CT scan with the pump on at 50 ml/hour. E8 said she heard R36 returned to the facility with the pump off, and the feeding flowing to gravity. E8 said she did not turn R36's pump back on and did not know who did. E8 said if the tubing is hooked up to the abdominal tube, the feeding will infuse to gravity. E8 also said she did not know when R36 returned to the facility, and was not notified when she returned. On 4/22/14 at 12:25 PM, E5 (Licensed Practical Nurse- LPN) said she turned R36's feeding pump back on between 11:00 and 11:30 AM. E5 said she noticed the feeding was flowing to gravity and the pump was turned off. E5 said she put the tubing back in the pump and set the pump to infuse at 50ml per hour. E5 said the tube feeding should not infuse to gravity and should be administered through a pump. A Facility faxed Nursing documentation dated 4/22/14 at 11:25 to R36's physician shows "at 9:50 AM I hung a new bag of feeding, at lunch she threw up. I noted only 500ml in bag. State surveyor observed bag to gravity at 10:50 AM. This resident left facility for appointment at (medical center). She got approximately 1000mls of feeding in about an hour". Z1 (physician) faxed response on same form dated 4/22/14 at 2:15 PM states "need to be cautious with feeding. 1000ML certainly excessive. Continue to follow. Use PUMP" R36's nurse notes dated 4/22/14 at 12:12 show "at 11:55am I observed resident coughing and she had thrown up at the lunch room table. I noted only 500 ml in feeding bag, new bag was hung at 0950 am..." R36's nurse notes dated 4/22/14 at 23:39 show "Tube feeding infusing as ordered. Resident up in w/c (wheelchair) and in dining room for supper when resident had 2 emesis. Tube fdg shut off and resident put back to bed. No further emesis noted and at 8:15 PM, tube feeding restarted at regular rate..." The nursing notes contain no documentation of the physician being notified of mulriple emesis, or that the tube feeding was shut off. R36's nurses notes for 4/23/14 at 0038am (12:38 AM) show, "tube feeding held at this time. pt had a small emesis prior to 12M rounds...abd(abdomen) is soft and slightly distended...will continue to monitor closely and restart tube feeding when pt better able to tolerate..." There is no documentation that the physican was notified of any emesis or that the tube feeding was shut off. R36's nurse noted dated 4/23/14 at 2:11 AM shows "Pt in bed with coffee ground emesis, large amt noted. Odor of stool noted. Dr notified...discuss with family and if they wish her to be treated then send to ER..." R36's emergency room documentation dated 4/23/14 at 5:45 AM shows "pt had 1000 mL of feeding free flow into g tube because tubing was disconnected from pump. pt vomiting unknown amount of times...Impression and Plan - Diagnosis - Hematemesis, Acute Upper GI Bleed". On 4/23/14 at 9:50 AM, E2 (Director of Nursing - DON) said R36 left the faciity on [DATE] in the morning for an appointment at the local hospital. E2 said the enteral feeding was infusing on a pump, and the only person who accompanied R36 was E18 (transport/maintenance). E2 said when E18 brought R36 back to the facility he took her to the sitting room on the 300 wing, but did not notify a nurse R36 was back in the facility. E2 said R36 has gone to a Doctor's appointment out of town (over an hour away), accompanied by a CNA, via the facility transportation van, with her enteral feeding infusing on a pump. E2 said E18 and the CNA's are not qualified to monitor a resident, or a tube feeding. E2 said E18 and the CNA's have not had any training to care for an enteral feeding or a feeding pump. E2 said only a nurse is qualified to care for the enteral feeding, feeding pump, and monitor the resident. E2 said R36 should not have left the facility with her enteral feeding infusing. On 4/23/14 at 9:50 AM, E2 said when the transporter returns a resident to the facility, he is supposed to report to the nurse that the resident is back. E2 said E18 did not do this on 4/22/14, "he just wheeled her (R36) back and left". The facility policy dated 11/03 titled "Enteral Tube Feeding Administration Guideline" shows "A resident who is fed by a nasogastric, gastrostomy, or jejunostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration..." "27. Resident will be monitored for: changes in site-drainage or foul odor, signs and symptoms of aspiration, abnormal lung sounds, shortness of breath, fever, distended abdomen, diarrhea, pain, appearance and volume of gastric aspirates, heartburn, vomiting, abdominal pain or cramping, constipation, rapid hear rate, agitation, coughing, choking..." The 11/13 facility policy "Enteral Feedings-Safety Precautions" states "2. Slow, continuous, pump-regulated feedings are generally better tolerated than gravity or syringe feedings." "Preventing Aspiration 2." Check gastric residual volume...every 6-8 hours after target feeding volume and rate have been established." 5. "Recognize the risk factors for aspiration, including: d. Vomiting" "Report unusual findings and/or signs of complication to the Physician" The facility "Nursing Services Policy and Procedure - Tube Feeding Potential Problems/Complications" states "Symptoms - Heartburn or vomiting, coughing, choking Immediate Action - Stop the tube feeding Notify health care practitioner Prevention- Do not administer feeding if stomach feels full, is distended, or if person is vomiting"

Based on observation, interview and record review the facility neglected to follow their policy and procedure for Neglect, Lab, Xray and Diagnostic test result, change in resident condition/status and policy on pain by not assessing a resident with signs of pain, not obtainting Xray results within the same day, neglected to include report of a residents pain and pending Xray to the next shift for a resident with a complaints of pain and not bearing weight on her leg. This resulted in a resident not receiving any assessment for pain or pain management for 36 hours for a resident with a [MEDICAL CONDITION] and femur. This applies to 1 of 1 residents (R1) reviewed for pain and assessment in the sample of 3. The findings include: The 2/25/14 MDS(Minimum Data Set) shows R1 was admitted to the facility of 11/1/10 with multiple [DIAGNOSES REDACTED]. On 9/3/13, R1 was assessed to require the use of a stand lift for transfer. On 3/4/14 at 6:13 AM, E9 LPN (Licensed Practical Nurse), documented R1 was leaning to the right and stating her left leg/hip hurts. R1's ROM (Range of Motion) as usual to lower extremities. Stiffness noted. CNA's (Certified Nursing Assistant) report that she will not bear weight on the right leg. No bruising/swelling noted. Doctor paged. At 11:11 AM, E2 DON (Director of Nurses), documents " X-ray here." The 3/4/14 Patient Report of X-ray documents R1 had right side weakness and pain. The procedure performed was an X-ray with 2 views of the right hip. The findings show an acute femoral neck fracture. On 3/13/14 at 8:30 AM, Z2 (Xray company representative) stated she had received an order for [REDACTED]. Z2 stated it is not standard practice to give the results of the X-ray over the phone, but if the nurse asks, we will read the results to the nurse. Z2 stated "On this case, it looks like (Xray company) only called and told the nurse the result was being faxed at that time, the nurse did not ask for a reading of the results and therefore she was just told the result was being faxed to the facility." On 3/18/14 at 11:15 AM, E3 LPN (Licensed Practical Nurse), stated she was called by the Xray company and told the results from the X-ray were being faxed to the facility. E3 stated she checked the fax at 12:30 PM, 2:00 PM, and then called them again at 3:30 PM to tell them she had not received any fax and to re-fax the results . E3 stated she had come to the end of her shift at 3:30 PM and reported to E11 LPN, to follow up on getting R1's Xray results. The nursing schedule shows E11 worked on 3/4/14 from 2:00 PM to 10:00 PM. On 3/18/14 at 4:45 PM, E11 stated she did receive report on 3/4/14 from E3 that R1 had been complaining of pain and the facility was still waiting for the results of the hip Xray. E11 stated "I did check in on R1 when I gave her medications, about 9:00 PM. I was really busy during my shift and that was the first chance I had to see her. I asked her if she had any pain. She had no complaints of pain. She was already getting pain medicine 4 times a day." E11 stated she should have documented any signs of pain she had to make sure she was stable while waiting for her Xray results. E11 stated she had not performed any physical assessment of R1's hip or leg during her 8 hour shift. E11 stated "I did not think she was in any pain, she is very hard to assess. She had not had any falls and honestly I did not think it (her hip) was broken." On 3/18/14 at 5:30 PM, E13 RN (Registered Nurse) said she relived E11 at 10:00 PM on 3/4/14. E13 stated she did not receive report regarding R1's Xray report. E13 stated she would have called the Xray company and had them fax the results if she had been given any information about not having the results. E13 stated she stayed on shift until 2:00 AM on 3/5/14 and since she did not know of the X-ray she did not pass on report to the next shift to follow up on obtaining the results. The facility policy for Lab, X-Ray and Diagnostic Test Results dated 11/2013, documents 1. a. If the staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow. The nursing notes for R1 on 3/4/14 do not show any assessment performed by a nurse after E9's documentation at 6:13 AM. The nursing notes do not address a pain assessment or a physical assessment of R1's right hip. On 3/18/14 at 10:30 AM, E9 LPN, stated she first was aware of R1's pain and weakness of her leg on 3/4/14 when she paged the physician to get an order for [REDACTED]." E9 stated she was off the next night on 3/4/14 and returned to the facility on [DATE] at 10:00 PM. E9 said " There was another resident being sent out to the local hospital for a fracture, and then I wondered about (R1) and how her X-ray results were. I looked in her chart and could not find the X-ray result so I called the Xray company to have them fax the final report." The fax date and time of the result was 3/5/14 at 23:34 (11:34 PM). The nursing notes for R1 document E9 called the results to Z3 (Physician) at 11:39 PM, and new orders received to send to the emergency room if ok with family. E9 contacted the Power of Attorney and R1 was sent to the hospital on [DATE] at 12:09 AM. R1's Nursing Notes for 3/5/14 do not document any assessment of pain or physical assessment. The facility's 11/2013 Change in a Resident's Condition or Status policy states Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and /or status. 6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. On 3/6/14 at 12:44 AM, R1 was seen by Z4 (emergency room Physician) 36 hours after the original Xray was taken at the facility. Z4 documents R1 presents with lower extremity pain, lower extremity swelling and knee pain. The onset was 2 days ago. The course/duration of symptoms is constant and worsening. The symptoms are pain, swelling, tingling and numbness. The degree of pain is moderate, exacerbated by weight bearing. The relieving factor is none. On 3/10/14, R1 was discharged from the hospital. On 3/14/14 at 2:10 PM, Z3 (Primary Physician) stated she initially was going to discharge R1 on a pain medication "as needed", but due to family concerns regarding her lack of pain medications prior to her hospitalization , Z3 stated she scheduled the pain medication. Z3 stated R1 should have been assessed through the day and night while waiting for the Xray results. Z3 said the nurses should have assessed her leg and her pain level and documented their findings. On 3/13/14 at 11:40 AM, E2 DON said she was aware R1 had no documented assessment from 3/3/14 to 3/5/14. E2 stated E11 had documented a late entry on 3/6/14 because E11 said she forgot, and I asked her to enter the late entry. E2 stated there is a 36 hour time gap for any documentation of R1's pain and assessment while waiting for the Xray results. E2 stated "I am looking into that issue." On 3/14/14 at 2:10 PM, Z3 stated it usually takes a fall to get the fractures R1 had. She would have been in moderate distress, enough pain that she required intravenous narcotics to get her comfortable. Z3 stated the CT (computed tomography) scan showed the [MEDICAL CONDITION] to be 2-10 weeks old and there was probably an impaction injury or event to worsen her pain. Z3 stated using the stand lift would cause an impaction of a fracture. Z3 stated her concern was with the facility not acquiring the Xray results for 36 hours and during that time R1 would have been in pain and without enough pain medications to keep her comfortable. The facility's 11/2013 Pain Protocol policy states 1. The staff will identify individual who have pain or who are at risk for having pain. 2. The nursing staff will screen each individual for pain whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain. 3. The staff will identify the nature and severity of pain. 3b. The staff will observe the resident for evidence of pain: for example, while being repositioned. The 3/2013 facility policy for Abuse Prevention defines Neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or in the deterioration of a resident's physical or mental condition. The Orientation and Training of Employees shall include appropriate care delivery and treatment interventions for resident's with limited vision, hearing, communication, cognition, and mobility. 5. Protection of Residents and Staff - the nursing staff is additionally responsible for reporting on a facility unusual occurrence report the appearance of bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee.

Based on observation, interview and record review the facility failed to assess a resident for Range of Motion and Pain when an initial report was given about R1, not bearing weight on her right leg during transfer, to the nursing staff. This resulted in a resident waiting 36 hours in pain from a [MEDICAL CONDITION] and femur. This applies to 1 of 1 residents (R1) reviewed for pain and assessment in the sample of 2. The findings include: The 2/25/14 MDS (Minimum Data Set) shows R1 was admitted to the facility of 11/1/10 with multiple [DIAGNOSES REDACTED]. The 2/25/14 MDS shows R1 has severely impaired cognitive skills for decision making. Section B, Hearing, Speech and Vision shows R1 has unclear speech and rarely or never makes herself understood and rarely/never understands others. The functional status, Section G, of the MDS shows R1 requires extensive assistance with bed mobility and transfer. R1 also requires extensive assistance with dressing, eating, toilet use and personal hygiene. The functional limitation in Range of Motion shows impairment on both lower extremities and requires a wheelchair for mobility. On 9/3/13, R1 was assessed to require the use of a stand lift for transfer. On 3/18/14 at 10:45 AM, E7 CNA (Certified Nursing Assistant) stated she worked 3/3/14 from 2:00 AM until 2:00 PM. E7 stated about 4:30 AM- 5:00 AM on 3/3/14, R1 was trying to climb out of her bed. E7 stated she decided to get R1 up for the morning and began to dress her. E7 stated while she was dressing R1, R1 was moaning and groaning while being moved from the bed to the recliner. E7 stated R1 would not put any weight on her right leg and she was leaning in the chair recliner. E7 stated "I reported this to the nurse at 6:00 AM, the day shift nurse who had just started her shift." E7 stated that throughout the day R1 was transferred with the stand lift at least 5 times during the day shift. Not including the next 2 shifts. E7 stated "I see these people everyday and I know when something is not right. She (R1) seemed to be in a lot of pain." On 3/18/14 at 9:50 AM, E8 LPN (Licensed Practical Nurse), stated she was on duty 3/3/14 when the initial report of pain was identified. E8 stated the CNA had reported R1 appeared in pain while transferring with the stand lift and was not bearing weight on her right leg. E8 stated she had noticed R1 in a recliner favoring her left hip and was lying in fetal position on her right side. E8 said R1 did appear to have some pain but she had just received her pain medication at 5:00 AM. E8 stated she did not chart her assessment of pain or her positioning in the chair. E8 stated she only gave the scheduled pain medication. E8 stated because she did not see the incident of alleged pain, she did not believe it and did not want to chart anything that was not witnessed. E8 stated she made no attempts to observe any stand lift transfers during her shift. On 3/18/14 at 3:00 PM, R1 was observed lying on her left hip in bed. R1 stated her name but had no further verbal response to questions of pain or comfort. R1 had a blank stare when asked how she was feeling. The nursing notes for 3/3/14 do not document a pain assessment or physical assessment. A late entry note on 3/6/14 at 9:00 AM ( 9 hours after R1 was sent to the local hospital) documents an assessment for 3/3/14 at 10:00 AM. The late entry note reads "Resident appeared to be guarding left hip when placed in recliner in front of nurses station. Resident rolled self in a side-lying position on the right hip while in the recliner. This nurse (E8) assessed the left hip for any sign of injury. Resident expressed no signs of pain." When asked about the late entry documentation, E8 stated "I just forgot to chart her pain, but I reported it to the next shift." On 3/18/14 at 10:00 AM, E8 stated R1 should have been documented on at least every two hours and the assessment of her hip and pain should have been reported to the next shift. On 3/18/14 at 11:15 AM, E3 LPN stated she had worked on 3/3/14 and received report from E8 for her shift. E3 stated she did not receive any report of R1 having pain or difficulty standing with the stand lift. On 3/18/14 at 10:45 AM, E7 reported for work on 3/4/14 at 4:00 AM. E7 stated she again reported to E9 LPN, R1's signs and symptoms of pain and not bearing weight with transferring. E7 stated when she reported the symptoms to the nurse, she did not seem to know R1 began having pain on 3/3/14. On 3/18/14 at 10:30 AM, E9 LPN, stated she reported for work on 3/3/14 at 10:00 PM and did not receive report on R1's leg pain. E9 stated that when E7 reported for work at 4:00 AM on 3/4/14 she informed her about R1's leg pain and lying on her side. E9 stated she immediately assessed R1 at that time. E9 stated R1 was sleeping at 4:30 AM and did not seem to be in any pain or discomfort at that time. E9 stated R1 was re-assessed at about 5:00 AM on 3/4/14, after she was transferred out of bed into the recliner. On 3/4/14 at 6:13 AM, the nursing notes show E9 documented R1 was leaning to the left side and stating she had right hip pain. ROM (Range of Motion) as usual to lower extremities. Stiffness noted. CNA report (R1) will not bear weight on the right leg. No bruising/swelling noted. MD (Physician) paged. On 3/18/14 at 11:15 AM, E3 said on 3/4/14 at 6:30 AM, she was given report on R1's hip pain and was told the doctor had been paged. E3 stated about 6:30 AM, Z3 (Physician) called an order to have an X-ray taken of R1's right hip due to pain and weakness. E3 stated she immediately called the X-ray company and requested the X-ray. E3 said she assessed R1 when she gave her medications at 11:00 AM on 3/4/14. E3 stated she had asked R1 if she had any pain and R1 just stared at her. E3 said sometimes R1 will shake her head yes or no to answer a question or she just has no expression at all. E3 stated R1 is non-verbal and she would not be able to say she is in pain. E3 stated through out the day on 3/4/14 she was leaning in the recliner and sleeping. The nursing notes for R1 on 3/4/14 do not show any assessment performed by any nurse after E9's documentation. The nursing notes do not address a pain assessment or a physical assessment of R1's right hip. On 3/13/14 at 3:40 PM, E3 stated she did check on R1 through the day on 3/4/14, but did not document her assessment. E3 stated she should have documented her assessment. E11 LPN, worked on 3/4/14 from 2:00 PM to 10:00 PM. On 3/18/14 at 4:45 PM, E11 stated she did receive report from E3 that R1 had been complaining of pain and were waiting for results of a hip X-ray. E11 stated "I did check in on her when I gave her medications, about 9:00 PM. I asked her if she had any pain. No I did not do any sort of physical assessment, she was already getting pain medicine 4 times a day." E11 stated she should have documented any signs of pain she had to make sure she was stable while waiting for her X-ray results. E11 stated "I did not think she was in any pain, she is very hard to assess. She had not had any falls and honestly I did not think it (her hip) was broken." E13 RN (Registered Nurse) worked 3/4/14 from 10:00 PM until 3/5/14 at 2:00 AM. On 3/18/14 at 5:30 PM, E13 stated she had relieved E11 on 3/4/14 and E11 did not report R1's complaints of pain or that X-ray results were still pending from 12:00 PM. E13 stated had she been given report of the pain, she would have assessed R1 and called the X-ray company for the results of the X-ray. E13 stated because she did not receive report R1's hip pain and X-ray, she did not pass in report to the next shift the information. The March 2014 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. From 3/4/14 until 3/5/14, R1's MAR indicated [REDACTED] On 3/18/14 at 10:30 AM, E9 said she had returned to work 3/5/14 at 10:00 PM. E9 stated when she arrived, another resident was being transferred out to the emergency room and she wanted to see what R1's X-ray had showed. E9 stated she could not find an X-ray report and called the X-ray company for the results, 36 hour after the X-ray had been ordered. At 3/5/14 at 11:34 PM, the X-ray company faxed R1's X-ray results of an acute femoral neck fracture. On 3/18/14 at 10:30 AM, E9 stated once she received the X-ray report she paged Z3 and received orders to send R1 to the emergency room . R1's Nursing Notes for 3/5/14 do not document any assessment of pain or physical assessment. On 3/6/14 at 12:44 AM, R1 was seen by Z4 (emergency room Physician). Z4 documents R1 presents with lower extremity pain, lower extremity swelling and knee pain. The onset was 2 days ago. The course/duration of symptoms is constant and worsening. The symptoms are pain, swelling, tingling and numbness. The degree of pain is moderate, exacerbated by weight bearing. On 3/14/14 at 2:10 PM, Z3 (Primary Physician) stated it usually takes a fall to get the fractures R1 had. She would have been in moderate distress, enough pain that she required intravenous narcotics to get her comfortable. Z3 stated the CT (computed tomography) scan showed the [MEDICAL CONDITION] to be 2-10 weeks old and there was probably an impaction injury or event to worsen her pain. Z3 stated using the stand lift would cause an impaction of a fracture. Z3 stated her concern was with the facility not acquiring the X-ray results for 36 hours and during that time R1 would have been in pain and without enough pain medications to keep her comfortable. On 3/10/14, R1 was discharged from the hospital. On 3/14/14 at 2:10 PM, Z3 stated she initially was going to discharge R1 on a pain medication "as needed", but due to family concerns regarding her lack of pain medications prior to her hospitalization , Z3 stated she scheduled the pain medication. Z3 stated R1 should have been assessed through the day and night while waiting for the X-ray results. Z3 said the nurses should have assessed her leg and her pain level and documented their findings. On 3/13/14 at 11:40 AM, E2 DON said she was aware R1 had no documented assessment from 3/3/14 to 3/5/14. E2 stated E11 had documented a late entry on 3/6/14 because she said she forgot, and I asked her to enter the late entry. E2 stated there is a 36 hour time gap for any documentation of R1's pain and assessment. E2 stated "I am looking into that issue." The facility's 11/2013 Pain Protocol policy states they will identify residents in pain. The nurse will identify the cause and the severity of the pain. The facility's 11/2013 Change in a Resident's Condition or Status policy states the staff will notify the physician and the Nursing Supervisor of any change in a resident's medical condition.

Based on interview and record review the facility failed to obtain results for an X-ray procedure performed on a resident to rule out a fracture. This resulted in a resident with a [MEDICAL CONDITION] and femur waiting 36 hours before obtaining treatment. This applies to 1 of 2 residents (R1) reviewed for X-ray procedures in the sample of 3. The findings include: On 3/4/14 at 6:13 AM, E9 LPN (Licensed Practical Nurse), documented R1 was noted to be leaning to the right and stating her left leg/hip hurts. R1's ROM (Range of Motion) as usual to lower extremities. Stiffness noted. CNA's (Certified Nursing Assistant) report that she will not bear weight on the right leg. No bruising/swelling noted. Doctor paged. At 11:11 AM, E2 DON (Director of Nurses), documents " X-ray here." The 3/4/14 Patient Report of X-ray from the Xray company documents R1 had right side weakness and pain. The procedure performed was an X-ray with 2 views of the right hip. The findings show a Garden classification II acute femoral neck fracture. On 3/13/14 at 8:30 AM, Z2 (Xray company representative) stated she had record of an order for [REDACTED]. Z2 stated it is not standard practice to give the results of the X-ray over the phone, but if the nurse asks, we will read the results. Z2 stated " On this case it looks like (Xray company ) only called and told the nurse the result was faxed. On 3/18/14 at 11:15 AM, E3 LPN (Licensed Practical Nurse), stated she was called by the Xray company and told the results from the X-ray were being faxed to the facility. E3 states she checked the fax at 12:30 PM, 2:00 PM, and then called them again to tell them she had not received any X-ray result. E3 stated she had come to the end of her shift and reported to E11 LPN, to follow up on getting the results of the X-ray. On 3/18/14 at 4:45 PM, E11 stated she had received report from E3 that R1 had an X-ray performed and was not able to get the faxed report. E11 stated she continued to check the fax machine for results. E11 stated " I think I did try to call twice but each time I tried something came up and never did get to call the Xray company . So no I did not get any results, I just got busy." E11 continued " I did not think she was in any pain, she is hard to assess. She has no history of falls. And honestly, I didn't think it was broken anyway." E13 RN (Registered Nurse) said she relived E11 at 10:00 PM on 3/4/14. E13 stated she did not receive report about an X-ray result for R1. E13 stated she would have called the Xray company and had them fax the results if she had been given any information about not having the results. E13 stated she stayed on shift until 2:00 AM on 3/5/14 and since she did not know of the X-ray she did not pass on information to the next shift. On 3/18/14 at 10:30 AM, E9 LPN, stated she first was aware of R1's pain and weakness of her leg on 3/4/14 when she paged the physician to get an order for [REDACTED]." E9 stated she was off the next night on 3/4/14 and returned to the facility on [DATE] at 10:00 PM. E9 said " There was another resident being sent out to the local hospital for a fracture, and then I wondered about (R1) and how her X-ray results were. I looked in her chart and could not find the X-ray result so I called the Xray company and had them fax the final report." The fax date and time of the result was 3/5/14 at 23:34 (11:34 PM). The nursing notes for R1 document E9 called the results to Z3 (Physician) and new orders received to sent to the emergency room if ok with family. E9 contacted the Power of Attorney and R1 was sent to the hospital on [DATE] at 12:09 AM. On 3/18/14 at 4:00 PM, E2 stated it is the floor nurse's responsibility to obtain X-ray results within 2 hours. If the nurse is at the end of their shift they are to report off to the next shift to follow up on and make sure to get the results. On 3/14/14 at 2:00 PM, Z3 (Primary Physician) stated she was concerned the X-ray company did not call the nursing home and report the fracture to the nurses. Z3 stated the injuries that (R1) sustained, seemed to happen from some sort of fall or trauma. Z3 said the 36 hour delay in obtaining the results could place (R1) at risk for [MEDICAL CONDITION] and pneumonia. The facility policy for Lab, X-Ray and Diagnostic Test Results dated 11/2013, states the staff who receives the order for testing is to obtain the results or report to the next shift to obtain the results.

Surveyor: SIMERLY, JULI Based on observation, interview and record review the facility failed to ensure resident safety by not removing hot packs from a resident's back. This failure resulted in R5 sustaining second degree burns to the middle of his back identified on 11/18/12. This applies to 1 of 15 residents (R5) reviewed for safety in a sample of 15. The findings include: The physician's orders [REDACTED]. The Minimum Data Set of 2/26/13 shows that R5 scored a 14 for Cognition. (No impairment) The facility incident report dated 11/18/12 states, "Floor nurse explained burns to resident and resident's response was "the hot packs were on too long." Upon further investigation, floor nurse found hot packs in resident's room near the sink. (...it was found that resident removed hot packs later that day (11/17/12) but he is unsure of time.) Upon my investigation it has been found that (a) contracted physical therapist applied hot packs to (the) resident's back on 11/17/12 per resident's request related to back pain. The Therapist mis-communicated with staff to remove hot packs and failed to return to remove hot packs after appropriate time..." The incident report also states, "Two of the burns (blisters) were ruptured and measured 2 x 2.5 cm. Third burn (blister) was not ruptured and measured 3 x 3cm." On 4/29/13 at 12:30 PM, R5 stated, "The therapist put the heating pad (hot packs) on and I left the (therapy) room. I think they were on for several hours. I had a back injury in the past so I don't really feel pain anymore. It was just as much my fault as it is his. I have to have help with a shower and that's when they found the blisters. (Z1- Therapist) came and talked to me, he was very upset and he cried." On 4/30/13 at 9:00 AM, Z1 stated, "I put moist hot packs on his back, I have done it many times before and never had a problem. Sometimes I will take them off and sometimes nursing will. I thought I communicated with nursing (to take them off) but maybe I didn't. They were probably on for about 40 minutes. " On 5/1/13 at 9:30 AM, R5's back was assessed with [REDACTED]. R5 has a softball sized area to his mid back directly over his spine. The area is red with an open area in the center that is draining a small amount of serous drainage. R5's physician's orders [REDACTED]. "

Based on observation, interview and record review the facility failed to identify risk factors and implement strategies to prevent the development of pressure ulcers. The facility failed to identify pressure ulcers prior to Stage II, and to implement measures to prevent a wound from becoming infected. The facility failed to notify the physician and family of the development of a wound. The facility failed to obtain wound treatment orders, and to ensure treatments orders were followed. The facility failed to completely assess and document the wound characteristics of a new pressure ulcer. This applies to 3 of 4 residents reviewed for pressure ulcers in a sample of 17. (R5, R8, R1) These failures contributed to R5 developing a foot wound initially found with devitialized tissue and signs of infection. The findings include: 1. R5's Nurses' Notes signed by E3 (Registered Nurse - RN) dated 5/7/11 at 4:30 PM states, "Called to look at resident's foot by E16 (Licensed Practical Nurse - LPN) at the request of the husband who asked E16 to look at the foot because she has foot pain. E16 removed the sock and noted very strong foul odor. A dressing was removed from the wound by E16. This writer noted a strong foul odor when entered the room. Noted left outer aspect open area below little toe. Noted 1 cm yellow center, 1/2 cm red area around this followed by sloughing of skin around this. Light red around top of foot warm to touch. Unable to determine if tunneling. States to husband that it "hurts very much". Reported concerns to husband about infection and pain. Husband expressed that he would like her to go the Emergency department for evaluation." The nurses' notes document the physician was notified and ordered the resident sent for a wound evaluation and treatment at the hospital. The Emergency Physician note dated 05/07/11 documents, "The patient presents with a left foot ulcer. The onset was 2 weeks ago. The character of symptoms is pain, redness, swelling and drainage. Risk factors consist of bedridden and patients non-ambulatory. Patient wears a plastic brace on the left foot due to chronic inversion of the foot." The Emergency Department treatment on 5/7/11 included wound cleansing and application of a dressing. R5 was prescribed to take an antibiotic for 7 days. The wound culture report dated 05/12/11 documents "1+ gram positive cocci in pairs, 3+ mixed growth of gram positive cocci and gram positive rods, coagulase negative staphylococcus species and diphtheroids." R5 was referred to the wound clinic for further evaluation and treatment. The Physical Therapy Evaluation notes for R5 on 2/9/11 documented R5 was referred by the nursing staff because she had complaints of foot pain with range of motion exercises. R5 was assessed as non-ambulatory, with muscle weakness and is dependent on a mechanical lift for functional transfers. The physical therapy recommendation on 2/9/11 was to use an ankle foot orthotic (AFO) to the left foot to improve mobility and function. The surveyor was unable to find when the AFO was initiated in the medical record. On 5/17/11 at 2:45 PM, Z2 (R5's husband) stated R5 had been wearing the brace for about 6 weeks. Z2 stated R5 always wore socks under the brace and he often helped remove the brace when the staff put her in bed for the night. Z2 stated the staff usually kept her socks on, and he was not certain how often they checked the condition of her skin. Z2 stated on May 7th, R5 was complaining a lot about her foot hurting. Z2 noticed a smell from her foot, (he did not remove her socks) and asked the staff to check it out. Z2 stated, "When the staff removed the sock, there was a bandage on it, it was a sticky kind and it was all bunched up". The previous nurses' notes from March 1, 2011 through May 7, 2011 were reviewed. No assessment information or information regarding a wound on R5's left foot was recorded prior to May 7th. There was no documentation regarding the use of a foot brace. R5's care plan dated 5/2/11 states documents a Stage II pressure ulcer on the left lateral foot, related to contracture of the foot and limited mobility. R5's care plan related to comfort dated 5/2/11 documents R5 has a skin breakdown to the left heel. There was no plan of care regarding the use of a foot brace. There was no documentation that the physician or family was notified prior to May 7th. The physician progress notes [REDACTED]. The physician did not document any concerns regarding the development of a wound on a the left outer foot. The Physician Order Sheet (POS) dated 05/01/11 shows R5 is low risk for skin breakdown, and to assess the skin weekly. R5's [DIAGNOSES REDACTED]. There are no physician orders regarding the use of a foot brace or application of the [MEDICATION NAME] wound dressings prior to 05/07/11. The treatment record for R5 documents a [MEDICATION NAME] dressing was applied on 05/01/11. The facility provided a body diagram dated 05/02/11 where an opening was recorded on the left outer foot. Measurements were recorded, but no wound characteristics, staging or assessment was documented. On 5/17/11 at 1:10 PM, E18 (Licensed Practical Nurse - LPN) stated R5 did wear a brace on her left foot. E18 stated R5 has had problems with her feet swelling, and her skin rubbing on the brace could have been what caused the wound to develop. E18 stated she had no answer as to how the wound got infected. E18 stated R5 had been using the brace for a couple of months. R5's weekly shower sheets and skin checks were requested. E2 (Director of Nurses- DON) on 5/17/11 at 2:05 PM submitted 2 forms for the month of April and stated no sheets had been completed for May. E2 stated, "The same CNA (E19) has given R5 her last 4 showers and he stated he does not remember anything prior to the start of the dressing changes whenever that was". On 5/17/11 at 3:30 PM, E16 (LPN) stated, "I was here when Z2 told me R5's foot was hurting. I took off the sock and there was a bunched up [MEDICATION NAME] dressing on the foot. There was a foul odor, and I asked the RN (E3) to come take a look at it." E16 stated she was not aware before that day that R5 had a wound on her foot. E16 stated she doesn't always work R5's wing, she works on whatever they assign her. On 5/17/11 at 3:40 PM, E3 (Registered Nurse - RN) stated, "It (May 7th) was my first day of work here; I was assigned on another wing. E16 asked me to look at the foot, and there was a very foul odor. I documented everything in the nurses' notes, and I talked to Z2 about the potential infection of the wound." The facility policy for Pressure Ulcer/Prevention/Skin Care states the physician and family will be notified of skin breakdown or decline in wound and orders will be obtained and carried out as appropriate and the care plan updated. 2. R8's face sheet documented that R8's [DIAGNOSES REDACTED]. R8's Minimum Data Set (MDS) of 3/4/11 showed a Cognitive Summary Score of 4 (0-7 severe impairment). The same MDS showed that R8 had no behavioral symptoms. R8 required extensive assistance of 2 or more persons for bed mobility. R8 was dependent on 2 or more persons for transfer. R8 had range of motion limitation on both sides, of her upper and lower extremities. R8 was occasionally incontinent of urine. R8 was at risk for pressure ulcer, no skin conditions were documented. A hospital discharge summary dated 1/28/11 showed that R8 was hospitalized for [REDACTED]. (discharged [DATE]) A facility body assessment sheet dated 2/3/11 showed that R8 had no open areas on her return from the hospital. R8's Braden Scale (tool for predicting pressure ulcers) showed a score of 15 on 2/24/11. (15-18 = mild risk) R8's Nursing Notes dated 5/8/11 at 7:00 PM documented that R8 was found with a 0.7 cm x 0.5 cm on the end of her spine. R8's May, 2011, Physician's Order Sheet showed a treatment order on 5/13/11 for TAO (Triple Antibiotic Ointment) and [MEDICATION NAME], daily and as needed to the lower spine. The Weekly Pressure Ulcer Report dated 5/16/11 had no documentation regarding R8's pressure area. R8's Daily Medicare Skilled Nursing Documentation sheets dated 5/13/11 through 5/16/11 showed that R8's skin was was normal and no pressure ulcer was present. A skin care plan dated through 6/1/11 documented the following on 2/3/11 resident is at risk for alteration in skin integrity related to limited mobility due to [MEDICAL CONDITION], bladder incontinence, and total dependence at this time. On 5/13/11 the same care plan documented "scab off to lower spine, red, beefy, granulation present. " The approaches included to turn and reposition every 2 hours and as needed, and to use pillows to position. On 5/16/11 at 12:30 PM, R8 was observed sleeping in her bed. R8 was laying positioned on her back. On 5/17/11 at 9:45 AM R8 was observed in her bed positioned on her back. On 5/17/11 at 11:05 AM, R8 was in her bed, positioned on her back, E4 Certified Nursing Assistant (CNA) was asked to assist in a skin check of R8. E4 turned R8 on her left side. R8 had a stage II area of pressure to her sacral area. No dressing was present. E4 was asked about R8's positioning to eliminate or reduce pressure to her lower back. E4 said " I can use a wedge cushion behind her back after she has lunch." E3 Registered Nurse (RN) was made aware at 11:45 on 5/17/11, that R8 had no dressing to her sacrum. At 11:45 AM E3 said " I did the treatment but we are gonna change it . I don't think it is the right one for her." 3. The Physician's Order Sheet of May 2011 showed R1 had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) Asssessemnt Reference Date (ARD) of 12/1/10 and 3/1/11 both assessed R1 as having no cognitive deficits and no memory problems. The MDS's showed R1 did not walk during the assessment period and had no upper or lower extremity impairment. During this assessment period R1 was occasionally incontinent and wore incontinent briefs. The assessments showed R1 was at risk for pressure ulcers and had one Stage II on previous assessments. Braden scale of September 2010 showed R1 score mild risk for skin break down. Nurse's note of 9/5/10 showed R1 uses a mechanical lift to transfer into bed. Nurse's note dated 9/15/10 at 8am, documented "New open area 2.0 x 1cm on coccyx." According to nurse's note of 9/3/10, R1 was sent to the hospital related to altered mental status and readmitted on the same day with a foley catheter. Nurse's note dated 11/6/10 showed R1's foley catheter was discontinued this date. Nurse's note dated 10/13/10 at 9am documented R1 had open area to right labia measuring 1.5cm x 0.4cm and abrasion caused from shearing to left superior leg (1.5cm x 0.5cm). R1's nurse's note dated 5/3/11 (6a-2p) documented, "Resident has blister 2cm by 1cm wide. Serous/clear fluid filled in the middle of back. Intact - has red line across back. (Incontinent brief) hits this area of tenderness." There is no evidence to show that R1's skin was monitored before the area became a Stage II. The skin integrity care plan dated 9/7/10 documents at risk for skin integrity related to: "Braden scale mild but treated as high risk d/t recent hospitalization , DM II, Chronic [MEDICAL CONDITION] (Obstructive [MEDICAL CONDITION] Disease), is occasionally incontinent of bladder." A approach listed is "Skin checks every shift and document weekly status of skin checks." The care plan does not mention an open area to R1's coccyx or that R1 had a foley catheter at this time. The same skin integrity care plan dated 10/13/10 showed R1 had an open area to the labia measuring 1.5cm x 0.5cm and an abrasion to the left superior leg which was caused by shearing from the hoyer sling. The care plan fails to identify the cause of the wound to the labia or risk factors associated with the development of a wound to this area.

Based on observation, interview and record review the facility failed to prevent 2 low risk residents from developing pressure ulcers to the right heel, failed to identify the pressure ulcers at a Stage I and failed to identify and remove the cause of the pressure. These failures resulted in R30 developing a Stage II ulcer to the right heel on 07/21/2011 and R31 developing a pressure ulcer to the Right heel on 7/19/11. This applies to 2 of 3 residents reviewed for pressure ulcers in a sample of 12. (R30,R31) The findings include: The Physician order [REDACTED]. R30's [DIAGNOSES REDACTED]. The resident admission notes for R30 dated 07/02/2011 at 3:30 PM, states, "Skin assessment completed, see head to toe assessment sheet." The Head to Toe Assessment Sheet for R30 dated 07/02/2011 shows the right foot is clear of tissue breakdown. The Pressure Sore Risk Assessment score for R30 on 07/02/2011 is 19 (indicates resident is at low risk to develop pressure). The POS (July 2011) identifies R30 at High Risk for skin breakdown, and to assess the skin every shift, turn and reposition per facility policy. The Treatment record for July 2011, shows the nurses signature for each shift since R30 was admitted . There is no documentation of open areas or pressure. The nurses' notes dated 07/21/2011 written by E17 (Wound Nurse) states, "R30 noted to have Stage II right heel-ulcer 3.5 cm x 4.0 cm; ulcer has 3.0 cm x 2.5 cm red open area in center with mushy white edges; right heel lift boot applied." On 07/25/2011 at 1:50 PM, E17 stated, "I was notified (on 07/21/2011) to check R30's right heel. That was the first I was aware of a issue with her heel." On 07/25/2011 at 2:30 PM, E16 (Licensed Practical Nurse - LPN) stated, "I check all areas of the body for breakdown. If there are no new open areas, we don't have to chart anything. If there is a new area we are to fill out a wound report. Wound assessments are done once a week." On 07/25/2011 at 2:50 PM, R30's right heel was observed during a dressing change by E17. R30 denied having any heel pain and stated, "I did not know there was something wrong (with the heel). They just started putting the dressing on it." The nurses' notes dated 07/25/2011 written by E17 (Wound Nurse) states, "Right heel noted now to be 4.0 cm x 4.0 cm Stage IV, ulcer has 3.0 cm x 2.5 cm red open area in center, edges are mushy, white along with some black blue areas surrounding the wound." R30's care plan was updated on 07/21/2011 to address the pressure ulcer treatment to the right heel. There was no previous pressure relief measures identified in R30's care plan. 2. The physician's orders [REDACTED]. R31's Braden Scale dated 6/7/11 shows that R31 scored a 13 (Indicating that R31 is low risk as 12 or < = high risk). Nurse's Notes dated 7/19/11 states, "Right outer heel wound- 3.5 cm x 1.5 cm, red/black, closed area. Resident currently getting skin prep to right heel every shift." The Pressure Sore/Wound Admission and Weekly Flow Sheet shows that R31 has a Stage I pressure area to the right outer heel. The area is described as "red/black closed area". On 7/26/11 at 10:55 AM, E17 was observed as she assessed R31's right heel wound. R31 was positioned in bed on her right side. R31 had large foam heel suspension boots in place and R31's right inner heel was resting on the boot. R31's boot was removed by E17 and R31's wound was observed as dry , yellowish/tan scabbed area. A small amount of necrotic tissue was also noted at the top of the wound bed. E17 measured the wound as 2 cm x 4 cm. E17 stated, "Last week it was just red with a small black area on the top. Now I would call it unstageable because I don't know what is underneath that. " E17 was asked what was causing the pressure to R31's heel. E17 stated, "I will have to look when she is up to see if the boot is rubbing or what is causing it. She usually doesn't lay on her side."

Based on record review and interview the facility failed to ensure a resident's safety in a sit-to-stand lift for a resident who was unable to bear weight. This resulted in R1 sustaining a fractured left 3rd rib on 8/24/10. This applies to 1 of 7 residents reviewed for falls in a sample of 17 (R1). The findings include: Restorative Nursing Assessment/Progress Notes dated 6/15/10 showed R1 has displayed behaviors of going "limp" in stand lift, not bearing weight. A Functional Ability Assessment with same date showed R1's gait was unsteady and had poor standing balance. R1 likes the sit-to-stand lift and does not want to try the (mechanical sling lift) . The Falls care plan dated 6/15/10 showed R1 will not cooperate and bear weight and requires staff to use a sit-to-stand lift. There was no transfer assessment done for R1 prior to 8/29/10. The Nurse's note entry for 8/24/10 at 11am, documented R1 complained of pain with deep breathing and of her stomach hurting. R1 refused lunch. The Nurse's note of 8/25/10 at 12am, showed R1 complained of pain at a "7" on a scale of 0-10 in bilateral upper extremity. Pain medication was given. A Note documented at 8pm showed R1 refused to go to the dining room for supper. R1's nurse's note on 8/26/10 at 1:30am showed several attempts to get R1 up to bed, declined. Feet and legs were swollen. R1 complained of receiving too many medications. There was no documentation for 8/27/10. Nurse's note dated 8/28/10 at 10:20pm showed R1 complained of chest pain. Rated at a "10". Noted to be leaning to the right and complained of difficulty breathing. R1 stating, "Hurts when I breathe." Color was pale. R1 requested to go to the hospital. Transported at 10:40pm. Nurse's note of 8/29/10 at 5:20am documented R1 returned from the hospital with a [DIAGNOSES REDACTED]. The 6am note showed the (mechanical sling) lift was initated due to the fracture. On 8/31/10 a late entry was documented for 8/24/10 at 4:10am that showed R1 was unable to bear weight after being put in a sit-to-stand lift by a CNA. Additional staff were required to assist the resident out of the lift into a wheelchair. R1 asked the nurse (E20-Registered Nurse-RN), "What is wrong with her?" referring to CNA who was transferring her in the first place. R1 stated she was scared. At 6am nurse informed oncoming nurse that resident was in need of evaluation for (mechanical sling) lift. E20(RN) informed the CNA on how to properly use the stand lift and educated the CNA on the policy of transferring the resident via standlift from one room to another. The CNAs were told to use a (mechanical sling) lift and 2 assist to do transfers. On 5/17/11 at 3:10pm, E4 (CNA) said, she was called to assist with R1 that night. E4 said R1 was wearing a silk gown ("moo-moo") and her knees were crooked in the (sit-to-stand) lift and caused R1 to slide down in lift. R1's Social Service Progress Note dated 9/1/10, "SSD (Social Service Director) talked with POA (Power of Attorney) who stopped by to update staff (related to R1's hospital admission after a fall) He said they were still running tests. Doctor said something to POA about her falling. POA told doctor it was not a fall but due to the lift." The falls care plan dated 9/3/10 showed R1 had an incident with sit-to-stand lift in which she went limp and hung from sling. An approach was to use (mechanical sling) lift for all transfers. Nurse's note of 9/5/10 at 10p-6a, documented that R1 requested to have the nurse present during the mechanical sling lift transfer. On 5/18/11 at 10:15am, R1 stated that staff use the sit-to-stand lift to transfer her.

Based on observation, interview, and record review the facility failed to prevent a dependent resident from falling off the side of the bed. This failure resulted in R1 falling and being hosptalized on [DATE] for treatment of [REDACTED]. This includes 1 of 3 residents reviewed for falls with injuries. (R1) The findings include: R1's Data Set of 01/04/11 shows R1 is totally dependent with transfers and requires the assistance of two staff. R1 does not ambulate and is totally dependent with locomotion. R1's plan of care updated 03/29/11 states, "Resident is non-ambulatory uses (reclining) chair and is dependent on care staff to propel her to/from all desired destinations; Resident transfers to/from all surfaces using a (total) lift and assist of two." On 04/14/11 at 11:05 AM, E14 (Certified Nursing Assistant (CNA)) stated, "R1 could not bear weight. I have never seen R1 walk, attempt to walk or sit up at the side of her bed." On 04/14/11 at 11:10 AM, E10 (CNA) stated, "R1 has been a (total lift) for the last year. If a resident uses a (total lift), he or she does not bear weight. R1 does not walk; R1 does not try to sit up." On 04/14/11 at 11:55 AM, E13 (CNA) stated, "I have never seen R1 try to sit up or walk in the last year." On 04/14/11 at 12:30 PM, E12 (CNA) stated, "R1 has not ambulated in a little over a year. Definitely has not been weight bearing for six months, maybe a year or year in a half. I have never witnessed R1 turning in bed. She is dependent on staff for repositioning. Maybe a year ago she was able to set up (without assistance)." On 04/14/11 at 12:45 PM, E15 (CNA) stated, "R1 has not ambulated in last year. R1 requires staff assistance and verbal cues with maneuvering in bed. R1 would require staff assistance and cues for sitting up from laying down. She could not sit up independently." On 04/14/11 at 1:40 PM, E6 (CNA) stated, "I entered R1's room, we (E5 (CNA) & E6) were doing rounds. I saw R1 sitting up at the edge of the bed. R1 was sitting up and I laid her down. About five minutes later nurse and I heard 'help, help.' We found R1 laying on the floor." On 04//14/11 at 2:20 PM, E5 stated, "R1 was sitting on the edge of her bed. E6 was standing in the doorway. I asked E6 why R1 was sitting up and E6 told me R1 wanted to get up. E6 asked me to bring her the stand-lift. I took her the stand lift; I sat the lift in front of the door. Then, I took linen to soiled utility room. As I was walking into the soiled utility room, I saw E6 exiting R1's room. The lift was never moved, when I came out of soiled utility room. About five minutes later, I was walking toward room I had been in, and the nurse ran into R1's room. I also went into R1's room and R1 was on the floor. She was on her right side with head toward the end of bed. I think E6 left R1 on the side of the bed and resident tried to get up. I highly doubt E6 laid R1 down because R1 was not strong enough to sit up by herself." On 04/15/2011 at 1:00 PM, E7 (CNA) stated, "R1 was not physically able to sit up by herself. I heard one of other employees sat her up and left her there. She just left her sitting." On 04/15/11 at 1:05 PM, E9 (CNA) stated, " R1 could not sit up by herself. R1 required staff assistance to sit up." On 04/15/11 at 2:00 PM, Z1 (Physician, Medical Director) stated, " I have never seen R1 go from laying to sitting. R1's injuries are consistent with a fall from sitting to the floor. R1 should not be left sitting independently. It would be unsafe to leave R1 at beside. If R1 was sitting up and left the fall could have been prevented." The nursing note dated 04/04/11 at 9:30 PM states, "Called to room by E6 (CNA) as patient was yelling, 'help, help." Patient was on floor on mat, head facing to door, right side of right ankle deformed. Patient not moved. No other visible trauma." The facility incident report dated 04/04/11 states "HISTORY OR PRESENT ILLNESS: Resident observed on floor next to bed (landing strip in place). Resident had trauma to right side lower extremity. Power of Attorney and Physician notified. Transferred to emergency room per ambulance. Resident repositioned to EMT, 'I was trying to get to my chair. ' Resident admitted with multiple lower extremity fractures." The hospital History & Physical from 04/04/11 states, "This is an [AGE] year-old demented female...She has been non-ambulatory for over two years and nursing there stated that she sat up and started to get up to walk out of bed, fell on the floor...LABORATORY/RADIOLOGY: X-rays show bilateral tibia fractures and right distal femur fracture that is displaced anteriorly....PLAN: I (ER Physician) explained that these are severe fractures. R1 is already non-ambulatory and she has fairly severe osteoporosis...it is unlikely she will be able to ambulate again."