Every finding on record at Complete Care at Silver Lake LLC

Based on observation, interview, document review, and policy review, the facility failed to ensure chicken salad sandwiches were served at the proper temperature. This deficient practice had the potential to affect 112 out of 114 residents.Findings included:During the second kitchen observation and interview on 01/22/26 from 11:54 AM to 12:15 PM, the following were made with the Dietary District Manager (DDM):A steam table pan was observed on the counter at the left end of the steam table. The steam table pan contained approximately 20 chicken salad sandwiches, stacked one on top of one another. At 12:05 PM the chicken salad sandwiches were being served on the tray line for room trays. A review of the temperature log for the lunch meal revealed the chicken salad sandwiches were within a safe temperature range. At 12:15 PM, the District Dietary Manager (DDM) obtained the temperature of the chicken salad on the chicken salad sandwich. The temperature was 54 degrees Fahrenheit (F). The DDM instructed that the DM stop service. The DDM stated there was another tray of chicken salad sandwiches in the refrigerator. The DDM removed the tray of sandwiches from the refrigerator. The DDM obtained the temperature of the chicken salad sandwiches, and the temperature was 57 degrees F. The DDM told the DM that they would need to stop serving chicken salad sandwiches until he was able to get them to the proper temperature.Review of the Sandwich, Chicken Salad (dice) - 1 Sandwich recipe revealed the chicken salad consisted of Diced, cooked chicken; mayonnaise; and pepper.During an interview on 01/22/26 at 12:42 PM, the Administrator stated all food should be served at the right temperature to avoid any residents getting sick.Review of the facility's policy titled Food: Preparation revised 02/2025 revealed, .All foods will be held at appropriate temperatures, less than 4l degrees F for cold food holding.

Based on observation, interview, and policy review, the facility failed to ensure the kitchen area was free from fruit flies. The facility failed to keep the kitchen clean and ensure bait boxes remained under the three compartments sink to deter pests as recommended by their pest control provider. This created the potential for the harborage of insects and vermin which had the potential to affect 114 out of 114 residents.Findings included:1. During the initial kitchen observation and interview on 01/20/26 from 9:30 AM to 9:54 AM, the following observations were made with the Dietary Manager (DM):a. The smaller three compartment sink in the corner of the kitchen, near the hand-washing sink, had approximately 15-20 fruit flies near the floor on the right side of the sink. On the floor, there were three bait boxes on the right side of the sink and two bait boxes on the left side. There was a one-ounce plastic, empty coffee creamer container on the floor on the right side of the sink and black debris. The Dietary Manager (DM) stated the area needed to be cleaned and confirmed they had a problem with fruit flies currently and in the past. He stated pest control came weekly and sprayed the area.2. During the second kitchen observation and interview on 01/22/26 from 11:54 AM to 12:15 PM, the following observations were made with the Dietary District Manager (DDM):a. The smaller three compartment sink in the corner of the kitchen had approximately 50-75 fruit flies near the floor at each end of the sink. There was one bait box on the floor on the left side of the sink. No other bait boxes were observed. The Dietary District Manager (DDM) stated pest control would treat fruit flies weekly. The DDM stated the area should be clean and food and debris should be removed. The DDM stated the Dietary Manager (DM) added cleaning the area to his weekly cleaning schedule and confirmed it had not been on the schedule until Monday.During an interview on 01/22/26 at 12:42 PM, the Maintenance Director (MD) stated pest control come to the facility weekly, and he encouraged the kitchen to ensure bait boxes are in place. The MD stated they could contact pest control in between weekly visits if they saw an increase in bugs. The MD stated they did not contact pest control this week and they were waiting for the weekly Thursday treatment which occurred on Thursdays.Review of the facility's policy titled, Pest Control Program dated 03/22/26 revealed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.

Based on observations, interviews, record review and policy review, the facility failed to ensure a call light was within reach for one resident (Resident (R) 1) out of 39 sampled residents reviewed for call lights. This failure had the potential to create a situation where the resident would need help and could not reach the call light, causing the resident's needs to go unmet.Findings Include:Review of 1's Face Sheet located under the Profile tab of the electronic medical record (EMR), revealed admission date of 10/07/25 with diagnoses which included Schizophrenia and intellectual disabilities.Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/24/25, located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. R1 was dependent on staff for all Activities of Daily Living (ADLs).Review of the Care Plan located in the EMR under the Care Plan tab and dated 10/08/25 revealed, .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.During an observation on 1/21/26 8:55 AM, R1 was in her bed calling out, saying help repeatedly. Observed at the top of her bed was a long black tube with a white end that was attached to her bed. The tube had a place at the bottom to attach to the call light. The white end was close to her mouth, and the black tube was malleable. The call light was placed above her head, approximately six inches.During an observation and interview on 01/22/26 at 3:43 PM, Registered Nurse (RN) 9 stated R1's call light was used with her breath. The call light was placed above her head, approximately six inches from her mouth. She stated that for R1 to use her call light, it needed to be in a position where she could blow into it. RN9 moved the call light closer to R1's mouth until the call light was in R1's mouth. R1 blew into the call light, and the call light turned on.During an interview and observation on 01/22/25 at 3:30 PM, Certified Nurse Aide (CNA) 10 stated R1 required total care, and her call light needed to be near her mouth for it to work. CNA 10 agreed it was not in place.During an observation and interview on 01/23/25 at 10:10, CNA 10 came out of R1's room. R1 had her call light in front of her face, approximately six inches away. R1 stated she could not use her call light.During an interview and observation on 01/23/26 at 10:19 AM, Licensed Practical Nurse (LPN) 5 stated that if R1 needed help, she would usually call out. She stated her call light was important and should be within R1's reach. LPN5 stated R1 has the type of call light that worked when R1blew into it. LPN5 attempted multiple times to get the call light in the correct position, while R1 continuously stated she could not use it. LPN5 finally took the call light and bent it into a fashion that worked when R1 blew into it. R1 stated she knew where her call light was and could use it. During an observation on 01/23/26 at 10:37 AM and at 10:42 AM, R1 turned on her call light; there was no one in R1's room at the time.During an interview on 01/23/26 at 10:37 AM, RN5stated that it was important that R1's call light was within reach. RN5 stated that all staff who work with R1 should know where to place R1's call light so R1 can use it when necessary.During an interview on 01/23/26 at 8:19 AM, the Director of Nursing (DON) stated that call lights should always be within residents' reach.Review of the facility policy titled, Call Lights: Accessibility and Timely Response revised 07/2025 revealed, . Staff will ensure the call light is within reach of the resident and secured as needed.

Based on interview, record review, and facility policy review, the facility failed to ensure one of five residents (Resident (R) 11) reviewed for unnecessary medications, continued to receive as needed (PRN) psychotropic medication (lorazepam) beyond 14 days, without an evaluation and documentation of the clinical indications to use the medication beyond the 14 days. This failure had the potential to place the resident at risk of adverse consequences.Findings include:Review of R11's electronic medical record (EMR) located under the Profile tab indicated the facility admitted the resident on 11/04/24.Review of R11's EMR Orders located under the Orders tab dated 12/23/25 indicated, lorazepam 0.5 milligrams (mg) [antianxiety medication] and take one half tab (0.25 mg) to be administered every four hours PRN [as needed] for agitation and restlessness.Review of R11's EMR Medication Administration Record (MAR) located under the Orders tab dated 12/25 indicated the facility administered the lorazepam on 12/24/25 one dose; on 12/26/25 one dose; 12/29/25 one dose; and on 12/30/25 one dose.Review of R11 EMR titled MAR located under the Orders tab for the month of 01/26 indicated the facility administered the lorazepam on 01/01/26 one dose; 01/08/26 one dose; 01/09/26 one dose; 01/11/26 one dose; 01/12/26 one dose; 01/15/26 one dose in the morning and one dose in the afternoon; 01/16/26 one dose in the morning and one dose in the evening; 01/17/26 one dose was administered; 01/18/26 one dose was administered; and on 01/21/26 one dose was administered.During an interview on 01/23/26 at 10:29 AM, the Consultant Pharmacist stated that any time a PRN psychotropic medication was ordered, there needs to be a 14-day stop date. The Consultant Pharmacist stated the medical provider then to reassess the continued use and provide justification and this needed to then be documented in the clinical record. The Consultant Pharmacist stated the use of PRN psychotropic medication applied to residents who received hospice services.During an interview on 01/23/26 at 10:38 AM, the Director of Nursing (DON) stated the PRN for lorazepam did not require a 14-day end date since R11 received hospice services.Review of a facility's policy titled Use of Psychotropic Medications dated 02/18/25 indicated, .Psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted.PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, until the attending physician or prescriber believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration.

Based on record reviews, interviews, and facility policy review, the facility failed to ensure a person-centered comprehensive care plan was developed for one of one resident (R)6 receiving wound care/treatment out of a total of 39 sampled residents. This deficient practice placed R6 at risk of worsening wounds, new wound development, and for unmet resident care needs and goals for care.Findings include:Review of R6's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed admission date of12/02/25 with diagnoses that included cellulitis, end stage renal disease (ESRD), dependence on renal dialysis, and difficulty in walking.Review of R6's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/25 located in the EMR under the MDS tab reflected R6 was at risk of developing pressure ulcers/injuries and had one or more unhealed pressure ulcers/injuries (PU/PI) present upon admission to the facility. The MDS reflected R6 had two Stage 3 pressure ulcers (Full thickness tissue loss) and moisture associated skin damage (MASD), a non-pressure skin issue.Review of R6's Care Plan located in the EMR under the Care Plan tab initiated on 12/04/25 (revision on 01/16/26) indicated, The resident has potential impairment to skin integrity of the r/t ESRD, anemia, obesity, HTN [hypertension], diabetes, use of anticoagulants, and has actual skin breakdown to the right gluteal fold, and coccyx. I have a terminal prognosis r/t [related to] cancer of the lung. Further review of R6's Care Plan revealed it was not individualized and person-centered regarding treatment/services for Stage 3 pressure ulcers and MASD care.During an interview and record review on 01/23/26 at 9:17 AM, the MDS Coordinator (MDSC) stated that she initiated the comprehensive care plan based on a Care Area Assessment (CAA) that was triggered. The MDSC reviewed R6's admission MDS triggered CAAs for Pressure Ulcer. The MDSC reviewed the comprehensive care plan and confirmed that the care plan reflected objectives and interventions for the risk for pressure ulcers but did not have an objective and intervention to address actual wounds or a time frame to achieve desired outcomes. The MDSC stated that the care plan should reflect resident goals, desired outcomes, care/services provided, and specific services to be provided as reflected in the comprehensive assessment. The MDSC stated that she was responsible for the admission, quarterly, annual, and change in condition MDS completion. The MDSC stated that the Unit Managers reviewed the care plans for changes and updates.During an interview and record review on 01/23/26 at 10:24 AM, the Unit Manager (UM) stated that she tried to review the care plans for the residents assigned to his/her unit at least weekly. The UM said that she looked for care plans to address specific care needs, appropriate interventions that could prevent avoidable decline.During an interview on 01/23/26 at 11:59 AM, the Director of Nursing (DON) could not identify appropriate interventions in the care plan for delivery of care for the two actual Stage 3 wounds or MASD.Review of the facility's policy titled, Comprehensive Care Plans revised 02/18/25 revealed, .All CAAs triggered by the MDS will be considered in developing the plan of care . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on record review, interview and policy review, the facility failed to ensure residents maintained good hygiene for two (Resident (R) 20 and 75) of five residents reviewed for activities of daily living (ADL) in the sample of 39 residents. This failure has the potential for the residents to develop skin infections, social isolation, and a general decline in health.Findings included:1. Review of R20's Record of admission located in the Profile tab of the electronic medical record (EMR) revealed admission date 11/26/24 with diagnoses including major depressive disorder, Parkinson's disease, dizziness, anxiety, and difficulty in walking.Review of R20's Care Plan Report, dated 04/23/25 in the Care Plan tab in the EMR revealed, [R20] had an ADL self-care performance deficit due to activity intolerance. A care plan dated 04/24/25 revealed [R20] had potential for skin impairment due to decreased mobility, high blood pressure (HTN), fragile skin, and poor safety awareness. An intervention for this was to R20's skin will be assessed on a weekly basis on my scheduled bath day.Review of R20's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/25 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS also indicated R20 required set-up or clean-up assistance with showers and bathing.Review of Documentation Survey Report V2 dated 12/25 and located under the Tasks tab of the EMR, revealed under Shower/Bathing/Personal Care R75 had NA (not applicable) on Wednesday and Saturday during the month of December 2025.Review of Documentation Survey Report V2 dated 01/26 and located under the Tasks tab of the EMR, revealed under Shower/Bathing/Personal Care R20 had NA on Wednesday and Saturday during the month of January 2026.During the Resident Council meeting on 01/22/26 at 2:09 PM, R20 stated she should be getting a shower twice a week and this was not happening. She added there had been times when she gathered all her shower items, placed them on her over the bed table, and she ended up falling asleep only to wake in the morning realizing no one came and got her for her shower. She stated she should get showers on Wednesday and Saturday.During a follow-up interview with R20 on 01/23/26 at 8:50 AM, R20 stated she still had not received a shower She added no one had come to talk to her about it and she had not refused the shower.2. Review of R75s Record of Admission, located in the Profile tab of the EMR revealed admission date of 12/05/23 with diagnoses including seizures, major depressive disorder, and difficulty walking.Review of R75's Care Plan Report, dated 03/11/24 and found in the Care Plan tab in the EMR revealed, [R75] had an ADL self-care performance deficit due to disease process, general body weakness, impaired balance, limited mobility, and limited range of motion (ROM). A care plan dated 03/11/24 revealed [R75] had potential for skin impairment due to hypothyroidism, polyneuropathy, and use of anticoagulants. An intervention for this was to R75's skin will be assessed on a weekly basis on my scheduled bath day.Review of R75's quarterly MDS, with an ARD of 12/20/25 and located in the MDS tab of the EMR, revealed a BIMS score of 14 out of 15, which indicated the resident had intact cognition. The MDS also indicated R75 was independent with showers and bathing.Review of Documentation Survey Report V2 dated 12/25 and located under the Tasks tab of the EMR, revealed under Shower/Bathing/Personal Care R75 had NA on 12/22/25 and 12/25/25.Review of Documentation Survey Report V2 dated 01/26 and located under the Tasks tab of the EMR, revealed under Shower/Bathing/Personal Care R20 had NA on 01/05/26 and 01/22/26.During the Resident Council meeting on 01/22/26 at 2:09 PM, R75 stated she was not getting showers all the time. She added she will ask for them, but she still does not get them.During an interview on 01/23/26 at 8:15 AM, Certified Nurse Aide (CNA) 5 stated if the resident refused showers or baths she would reapproach the resident a second time. If the resident continues to refuse, she notified the nurse. She added she does document the refusal in the resident's chart.During an interview on 01/23/26 at 8:19 AM, CNA3 stated the resident is reapproached and if they continue to refuse a shower or bath the nurse is notified. She stated she will also document the refusal in the resident's chart.During an interview on 01/23/26 at 8:21 AM, CNA2 stated she will reapproach the resident and let the nurse know. She added if the resident does refuse all together then she documents it in the resident's chart. She added she did work with R75, and she will refuse at times, and she does document the refusal.During an interview on 01/23/26 at 9:51 AM, Registered Nurse (RN) 4 stated they really try to accommodate the resident. If the resident refused a shower or bath we see if they wanted it at a different time. Staff will also educate the resident about the importance of bathing. She added both the nurse and the CNA document the refusal in the resident's chart.During an interview on 01/23/26 at 8:19 AM, the Director of Nursing (DON) stated the expectation is for the CNA to ask the resident about their shower. If the resident refused the shower, the CNA should tell their nurse so they can reapproach the resident. She stated the nurse is responsible to verify the CNA offered the shower and whether the resident received a shower or the resident refused. The DON stated they recognized there was a problem. Review of the facility's policy titled, Activities of Daily Living dated 12/15/23 revealed, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Policy Explanation and Compliance Guidelines.6. The facility staff will document the provision of ADL care and/or refusals of care.

Based on record review, interview and policy review, the facility failed to ensure one resident (Resident (R) 71) of two residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene out of a total survey sample of 39 residents. This failure has the potential for the residents to develop a general decline in health.Findings include:1. Review of R71's admission Record located in the electronic medical records (EMR) under the Profile tab indicated admission date 01/06/23, with diagnoses of dementia with agitation.Review of R71's Care Plan located in the EMR under the Care Plan tab dated 12/17/25 indicated that the resident has an Activities of Daily Living (ADL) self-care performance deficit related to (r/t) limited mobility.Review of R71's quarterly Minimum Data Set (MDS) located in the EMR with an Assessment Reference Date (ARD) of 10/16/25 indicated the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which resident was cognition was moderately impaired. The assessment indicated the resident was dependent on staff for baths/showers.Review of the POC (Plan of Care) Response History located in the EMR under the Task tab indicated the task for the resident was Shower/Bathing/Personal Care Monday and Thursday 7-3. The follow up question indicated, Was a shower given revealed the resident refused a shower on 12/25/22, 12/29/25, 01/01/26, 01/05/26, 01/08/26, 01/12/26, 01/15/26 and 01/19/26.During an interview on 01/20/26 at 3:10 PM, R71 stated she would like a shower, but she never gets one. She stated she only received sponge baths.During an interview on 01/22/26 at 3:30 PM, Certified Nursing Assistant (CNA) 10 stated she received the shower schedule with her resident assignment sheet. She stated she would ask the resident if they wanted a shower and if they refused, she would notify the nurse.During an interview on 01/22/26 at 3:43 PM, Registered Nurse (RN) 9 stated if a resident refused their shower she would attempt to educate the resident. If they continued to refuse, she would document the refusal and inform the family. She stated she would use the shower sheet to know who needed a shower for her shift.During an interview on 01/22/26 at 3:47 PM, RN8 stated if a resident refused a shower the CNA should tell her and she would document the refusal. RN8 stated she did not see any documentation in R71's EMR indicating she had refused her shower.During an interview on 01/22/26 at 3:57 PM, Unit Manager (UM) stated when a resident is scheduled for their shower and they refuse, the CNA should let the nurse know. The nurse should then speak with the resident to encourage her to take a shower. If the resident continues to refuse, the nurse should document the resident's refusal. The UM confirmed, upon review of the EMR there were multiple occasions where the CNA documented that the resident refused a shower but there was not any nursing documentation indicating they were aware of the refusal and that the nurse had spoken with the resident to discuss the refusal.During an interview on 01/23/26 at 8:19 AM, the Director of Nursing (DON) stated the expectation for the CNA was to ask the resident about their shower. If the resident refused the CNA should tell their nurse so they can reapproach the resident. She stated the nurse is responsible for verifying with the CNA showers offered and whether the resident received a shower or the resident refused. The DON stated they recognized there was a problem During an observation and interview on 01/23/2026 at 12:30 PM, R71 stated she had not had a shower in the last few days. R71's hair appeared oily and pungent.Review of the facility's policy titled, Activities of Daily Living revised 12/15/23 revealed, .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming.

Based on observation, record reviews, interviews, and facility policy review, the facility failed to follow care plan interventions to set the low air loss (LAL) mattress at 150 for one of one (Resident (R)66) out of a total of 39 sampled residents. This deficient practice placed R66 at risk of worsening non-pressure wounds, new wound development, and for unmet resident care needs and goals for care.Findings include:Review of R66's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R66 admitted to the facility on [DATE], initial admission date 06/05/25, with diagnoses that included Type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin, non-pressure chronic ulcer of right ankle with unspecified severity, non-pressure chronic ulcer of left heel and midfoot with other specified severity, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.Review of R66's Care Plan located in the EMR under the Care Plan tab initiated on 09/02/25 (revision on 12/18/25) indicated, the resident has potential for impairment to the skin integrity related to CKD (chronic kidney disease), diabetes, hemiplegia, limited mobility, history of skin breakdown, PVD (Peripheral Vascular Disease), anemia, HTN (hypertension), and has actual skin breakdown right medial foot and right heel. Interventions included low air loss mattress set at 150.During an observation on 01/22/26 at 12:51 PM, the Infection Preventionist (IP) stated that the pump settings for LAL mattresses were based on the resident's weight unless otherwise written in the physician orders. The IP said the residents were at risk of delayed wound healing or worsening of wounds if the LAL mattresses were too hard or too soft.Record review of an Order Listing dated 01/23/26 provided by the Director of Nursing (DON) reflected all residents with LAL mattresses and the physician ordered setting. The Order Listing indicated R73's LAL setting was 150.During an observation on 01/23/26 at 8:15 AM, R73's LAL mattress was set between 200 - 240.During an interview on 01/23/26 at 11:21 AM, the Unit Manager (UM) said that the nurses and nurse aides checked the residents' LAL mattresses to ensure that they functioned appropriately during rounds.Review of the facility's policy titled, Use of Support Surfaces revised 03/13/23 revealed, Policy: Support surfaces will be used in accordance with evidence-based practice for residents with or at risk for pressure injuries. Support surface refers to a specialized mattress, mattress overlay, or chair cushion designed to manage pressure, shear, microclimate, or friction forces on tissue. for powered devices, orthose requiring air, the licensed nurse will check each shift and prn (as needed) for proper functioning and/or inflation. guidelines for support selection may be utilized in obtaining physician orders.

Based on observation, record reviews, interviews, and facility policy review, the facility failed to follow physician orders and care plan interventions for one of one Resident (R)73 to set the low air loss (LAL) mattress at 250 out of 39 sampled residents. This deficient practice placed R73 at risk of worsening pressure wounds, new wound development, and for unmet resident care needs and goals for care.Findings include:During an observation on 01/21/26 at 1:45 PM, R73's LAL pump was set at greater than 300.Review of R73's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R73 admitted to the facility on [DATE], initial admission date 05/20/21, with diagnoses that included morbid (severe) obesity due to excess calories, cellulitis of left lower limb, and paraplegia (paralysis that affects the lower half of the body).Review of R73's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/29/25 located in the EMR under the MDS tab reflected R73 was at risk of developing pressure ulcers/injuries and had one or more unhealed pressure ulcers/injuries (PU/PI) present upon admission to the facility. The MDS reflected R73 had one Stage 4 pressure ulcers (Full thickness tissue loss with exposed bone, tendon, or muscle).Review of R73's EMR revealed in Orders under the Orders tab a verbal order dated 07/26/25 indicated, Low air loss mattress set at 250 every shift for wound, check setting and function.Review of R73's Care Plan located in the EMR under the Care Plan tab initiated on 11/16/22 (revision on 01/22/26) indicated, the resident has potential for altered skin integrity . and has actual skin breakdown to right medial gluteal fold, excoriation to bilateral buttocks, and left glute and left glute fold. Interventions included, low air loss mattress keep setting at 250.During an interview on 01/22/26 at 12:51 PM, the Infection Preventionist (IP) stated that the pump settings for LAL mattresses were based on the resident's weight unless otherwise written in the physician orders.During an observation and interview on 01/22/26 at 1:00 PM, the IP visualized R73's LAL and confirmed the pump was set between 300 and 350 and the static setting was turned on. The IP said that the static setting on the air mattress provided a stable and firm support surface. The IP said that it should only be used to allow a resident to have a firm surface when transferring from the bed. The IP said that R73's static setting should not be turned on.During an observation and interview on 01/22/26 at 1:05 PM, Licensed Practical Nurse (LPN)4 said that she checked R73's LAL pump each shift and that it was checked that morning. LPN4 said that the LAL setting should be at 250, as she pointed out a piece of tape with 250 written on it placed across the top of the pump. LPN4 visualized the LAL pump and confirmed it was set between 300 and 350 and the static pressure was turned on. LPN4 that she would go check the physician orders. LPN4 returned and stated the setting was supposed to be at 250.During an interview on 01/23/26 at 10:30 AM, the IP agreed that the pump setting between 300 - 350 was too high. She stated that the static setting was a firm mode and defeated the purpose of the alternating pressure therapy.Review of the facility's policy titled, Use of Support Surfaces revised 03/13/23 revealed, Policy: Support surfaces will be used in accordance with evidence-based practice for residents with or at risk for pressure injuries.Support surface refers to a specialized mattress, mattress overlay, or chair cushion designed to manage pressure, shear, microclimate, or friction forces on tissue. for powered devices, orthose requiring air, the licensed nurse will check each shift and prn (as needed) for proper functioning and/or inflation. guidelines for support selection may be utilized in obtaining physician orders.

Based on observations, interviews, record review, and policy review, the facility failed to ensure the indwelling urinary catheter tubing and collection bag were not in contact with the floor and a securement device was in place for one resident (Resident(R)24) of one resident reviewed for indwelling urinary catheters out of 39 sampled residents. This failure placed the residents at risk for transmission of infection to the urinary tract or injury from tension, pulling, and accidental dislodgement of the catheter from the bladder.Findings include:During observations on 01/20/26 at 1:00 PM, 01/21/26 at 9:37 AM, and 01/21/26 at 2:37 PM, R24's indwelling urinary catheter rested on the floor hanging from the right side of the bedframe. There was not a securement device in place to immobilize the catheter tube against the skin on R24's right or left thigh.Review of R24's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R24 was admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, unspecified hydronephrosis, and retention of urine.Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/25 located in the EMR under the MDS tab reflected R24 had an indwelling urinary catheter.Review of R24's Care Plan located in the EMR under the Care Plan tab initiated on 09/07/24 (revision on 01/17/26) indicated, the resident has a 16 French [16F] coude (curved-tip tube) indwelling catheter for enlarged prostate/retention and obstructive uropathy. Interventions include, Catheter strap. Change catheter strap weekly; Catheter Strap - check placement of catheter strap every shift.During an interview and observation on 01/21/26 at 2:55 PM, Licensed Practical Nurse (LPN)4 said that her responsibility was to make sure that the certified nursing assistants (CNAs) provided catheter care to residents. LPN4 said that she did not assess R24 to see if a catheter securement strap was in place. R24 was sitting up to the right side of the bed. LPN4 pulled back the cover placed across R24's lap and lower legs revealed that there was no catheter securement strap in place and the catheter drainage bag rested on the floor. LPN4 said that she would let the on-coming nurse know that R24 did not have a catheter securement strap in place. LPN4 did not attempt to replace a catheter securement strap.During an interview and observation on 01/21/26 at 3:15 PM, RN1 pulled the covers back to reveal that she replaced the securement strap to R24's left thigh. When the covers were pulled back, the indwelling catheter tubing was under R24's right thigh. RN1 repositioned the tubing from under R24's right thigh to under the right knee. A securement strap was observed on the left thigh. RN1 said that she was informed by LPN4 during shift change report that R24 did not have a securement strap in place. RN1 said that R24 was at risk of injury if the catheter tubing is pulled or could be yanked from the insert site.During an interview on 01/22/26 at 12:51 PM, the Infection Preventionist (IP) stated that resting an indwelling catheter drainage bag on the floor placed the resident at risk of bacterial contamination.Record review of LPN4's annual competency training dated 07/25/25 revealed LPN4did not have a competency skill check off for indwelling catheters.Review of the facility's policy titled, Indwelling Catheter Care revised 08/11/24 revealed, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. 6. Ensure straps are snug but not tight.

Based on observation, interview, and record review, the facility failed to ensure the infection prevention and control program was implemented to prevent the transmission of communicable diseases, including ensuring staff adherence to required personal protective equipment (PPE) and isolation precautions for two residents (Resident (R)2 and R91) who were in Contact/Droplet isolation out of 114 residents.Findings include:During an observation on 01/23/26 at 9:04AM, Licensed Practical Nurse (LPN)6 prepared Resident (R)2's medications then entered R2's room without donning (put on) PPE. Observation of R2's room entrance indicated signage for Contact/Droplet Precautions which indicated that gown, N95 mask, face shield, and gloves to be applied prior to entering the room.During an interview on 01/20/26 at 2:10PM, LPN8 stated that R2 was positive for flu.During an observation on 01/23/26 at 9:20AM LPN6 prepared R91's medications then entered R91's room without donning PPE. Observation of R91's room entrance indicated signage for Contact/Droplet Precautions.During an interview on 01/20/26 at 2:18PM, LPN8 stated that R91 was positive for flu.During an interview on 01/23/26 at 9:20AM, LPN6 stated he only used PPE when he makes contact with the residents and that he does not make contact when giving medications.During an interview on 01/23/26 at 9:53AM the Infection Preventionist (IP) stated that LPN6 should have donned PPE, N95 mask, face shield, gown, and gloves, before entering the room and doffed (take off) the PPE before exiting the residents' rooms.Review of the facility's policy titled Influenza Exposure Control dated 2024 indicated: 6. Infection control: a. Standard Precautions shall be maintained in accordance with facility policy.b. Contact/Droplet Precautions shall be implemented for residents with suspected or confirmedrespiratory virus with the presentation of symptoms. c. Staff shall follow the facility's transmission-based procedures while the Contact/Droplet Precautions are in effect.

Based on observation, interview, record review, and facility policy review, the facility failed to provide supervision to prevent residents from sustaining injuries from falls and/or a burn from hot water for three (Residents (R) 40, R96, and R38) of eight sampled residents reviewed for accidents out of a total sample of 32. R40 was assessed to require two staff members for bed mobility; however, the resident was repositioned by one staff member and slid out of bed, which resulted in actual harm of bilateral femur fractures. R96 suffered actual harm of second degree burns when water, which had been heated in the microwave for three to four minutes, spilled on her. R38 suffered a fractured femur, and facility staff failed to implement identified interventions to prevent further falls and injury The deficient practices caused residents to experience a decrease in quality of life and quality of care problems. Findings include: Review of the facility's policy titled, Incidents and Accidents, updated 03/14/23, revealed, It is the policy of this facility for staff to utilize [electronic medical record program] Risk Management Portal to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident . Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care . A Fall policy and/or program addressing prevention and intervention was requested and not provided. Review of the facility's policy titled, Microwave Safety, updated 03/29/22, revealed, To allow resident food and/or beverages to be reheated via microwave while remaining safe within the facility . Heat food/ beverages in 30 second increments until appropriate temperature is reached. 145 degrees F [Fahrenheit] 5. Stir food items during microwave heating to ensure even heat distribution. 6. Use a sanitized thermometer (using a sanitizer wipe safe for food service) to check for safe temperatures prior to service . 10. Supervise/assist resident at risks for burns or who need help to eat (as their care plan directs) to maintain their safety and dignity. 1. Review of R40's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), revealed R40 was readmitted to the facility on [DATE] with diagnoses of pneumonitis due to inhalation of food and vomit, metabolic encephalopathy, and muscle wasting and atrophy of multiple sites. Review of R40's Lift, Transfer, Reposition assessment, dated 09/18/24 and located under the Assessment tab in the EMR, revealed R40 required two staff for repositioning in bed. Review of R40's annual Minimum Data Set (MDS), located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 09/21/24, revealed R40 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. R40 was also coded as being dependent on staff in bed mobility. Review of R40's Care Plan, located under the Care Plan tab in the EMR and dated 09/19/24 revealed, The resident uses side rails to maximize independence with turning and repositioning in bed. Review of the facility's self-reported incident, dated 10/04/24 and provided by the facility, revealed R40 fell out of her bed when being turned by Certified Nursing Assistant (CNA)3 during incontinence care. The report read, . Resident had a witnessed fall this morning 10-04-24 at 7:00 am. Resident was being provided incontinence care and while rolled on her side residents legs started to slide off the bed. Resident then completely slid from the bed and landed on the floor on her right side. Resident denies hitting head, witness to fall also states resident did not hit her head. Resident was assessed by the nurse and had no complaints of pain and no injuries were noted. This afternoon 10.04.24 [sic] at approximately 1300 resident had a syncopal episode and was complaining of shortness of breath. Residents pulse ox [oximetry] was noted to be 87% on room air. Resident was placed on 02 at 2 liters via [by] nasal cannula and pulse ox increased to 95% Resident was also noted with and elevated pulse. Resident was assessed by NP and order [sic] was given to send to the ER for further evaluation . Review of R40's hospital CT Scan of Lower Extremity Bilateral results, dated 10/04/24 and provided by the facility, revealed, . Comminated fracture with impaction distal right femoral metaphysis .Comminated fracture with impaction distal left femoral metaphysis . During an interview on 01/21/25 at 9:30 AM, R40 stated she had fallen in October when a CNA rolled her over to the right side with the CNA standing behind her. R40 stated she was able to catch ahold of the bed railing to hold herself over to help staff. R40 stated she told the CNA that she was falling, and the CNA attempted to grab her leg, but she started falling and fell out of the bed that was in the high position. The resident stated the CNA was tall so she put the bed up high and then that was the height that she fell from. She reported that she had fractures of both legs, but the right leg fracture was worse than the left leg fracture. A phone interview was attempted with CNA3 on 01/22/25 at 1:52 PM and again on 01/23/25 at 10:07 AM. Voice messages were left each time with a call back number for CNA3 to call. No return phone call was received. During an interview on 01/23/25 at 11:46 AM, the Director of Nursing (DON) stated, [name of CNA2] was [R40's] CNA when this incident occurred. The resident [R40] had been turned to her side with [CNA3] providing peri care while the resident was holding onto the side rail. [R40's] legs began to slide off the bed and the aide attempted to get the resident not to fall. [CNA3] should have rolled [R40] towards her [CNA3] instead of away from her [CNA3]. The DON was asked how many staff members were required for repositioning R40 in bed as care planned. The DON stated, Two. The DON was asked how many staff members were assisting R40 in turning when this fall occurred and the DON stated, Only one, [CNA3]. The DON continued, We put [CNA3] on leave and before she took an assignment to return to work, [CNA3] was provided education on turning, repositioning and lifting of residents and of the door magnets. The door magnets will have, for example, TA2 XL which stands for total assistance of 2 staff members with XL standing for the size of the lift pad or sling to be used when using a lift for the resident. We even included this training for all staff. During an interview on 01/23/25 at 2:00 PM, the Administrator confirmed this incident was taken to QAPI (Quality Assurance Performance and Improvement), and a QAPP (Quality Assurance Performance Plan) dated 10/04/24 had been developed. Review of this plan revealed monitoring and compliance of this plan would be achieved by Performing random spot checks to observe staff compliance with care plans. Create a tracking log for high-risk residents to ensure plans are followed consistently. Assign the nurse manager or charge nurse to review adherence to the care plans weekly . Monitoring and follow up: Ongoing, with first evaluation at 30 days post implementation. Verification of this process was reviewed on 01/23/25 at 5:00 PM, and it was noted the facility had completed all training and implemented the door magnets on 10/06/24. The facility had completed the QAPI plan as outlined to this date. This was determined be past non-compliace with a verified compliance date of 10/6/24. 2. Review of R96's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 12/22/24 and located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE] and a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R96's cognition was intact. It was recorded R96 had diagnoses of chronic pain, anxiety, and multiple sclerosis. Review of R96's investigation report, dated 10/05/24 and provided by the facility, revealed, [R96] is a resident at [facility name] who is alert and oriented x 2-3 with a BIMS of 15. At approximately 3:55pm, the resident asked a Certified Nurse Assistant [(CNA)4] [name] to heat up her hot water. The staff member stated he heated up the hot water for approximately three minutes and brought it to the resident. While helping the resident, he accidentally spilled hot water on her. Nursing immediately responded to this and provided first aid cooling treatment to her hand/wrist. Then nursing removed clothing and performed a whole-body skin assessment. Several reddened areas were identified: the dorsal side of left hand and wrist, left upper thigh, middle of abdomen, and side of left breast. First-aid cooling compresses were immediately applied to the affected areas. The nurse practitioner was contacted and an order for Silvadene was placed. Nursing is administering cooling compresses frequently on the areas as well as providing pain medication as needed, and the resident has stated that this has been effective for pain. Responsible party notified. Currently, the resident is calm and in good spirits. The facility is investigating this incident. We are providing re-education for staff on safe heating procedures. Review of R96's 10/05/24 Summary for Providers note located in the EMR in the Progress Note tab revealed, . Left hand opened blister observed measuring 6.4x4.9x< [less than]0.1. Left breast, left abdomen and left thigh with fading redness . Review of R96's Wound Assessment Report, dated 10/08/24, located in the EMR under the Miscellaneous tab revealed the following burns: Location: left forearm/hand, Measurements Length: 24.00 cm, Width: 16.00 cm . Depth: 0.10 cm, Etiology: Second Degree Burn. Location: left breast, Measurements Length: 3.00 cm, Width: 7.50 cm . Etiology: First Degree Burn. Location: abdomen, Measurements Length: 31.00 cm, Width: 30.00 cm . Depth: 0.10 cm, Etiology: Second Degree Burn. Location: left anterior thigh, Measurements Length: 17.00 cm, Width: 21.00 cm . Etiology: Second Degree Burn. On 01/20/25 at 2:46 PM, R96 was observed in bed awake with a sleep cover over her eyes. R96 was asked if she had been burned by hot water. R96 stated, Yes. R96 stated water for her coffee spilled on her lap after she asked the Certified Nurse Aide (CNA) to heat the water. R96 stated the CNA accidentally spilled it on her left hand, stomach, breast, and left leg a few weeks ago. R96 stated she received second-degree burns, but it was half healed now. R96 stated a treatment was ordered for Silvadene. R96 stated she thought the CNA used the microwave in the employee breakroom and heated her water for four minutes. R96's hands and body were covered with her blanket. R96 refused for her left hand and other areas previously burned to be observed. On 01/22/25 at 9:04 AM, the nourishment room on station two was observed and at 9:06 AM the nourishment room on station one was observed. Both microwaves had safety signs posted and the microwave policy. During an interview on 01/22/25 at 10:40 AM, the Director of Nursing (DON) was asked about the incident on 10/24 when R96 experienced a second-degree burn after a CNA spilled hot water on her. The DON stated CNA4 did not work at the facility anymore. The DON stated CNA4 used the microwave in the nourishment room on station two and this was the first time this type of incident had occurred. The DON stated CNA4 heated the water up for three minutes and poured it in R96's personal cup. The DON stated as CNA4 was putting on the lid to R96's travel mug, the hot water hit the bedside table and spilled on to R96 as she sat in her wheelchair in her room. The DON stated CNA4 immediately called the nurse who was in the hallway and CNA4 also reported to her soon after. The DON went on to say a treatment order for Silvadene was immediately obtained. The DON stated R96's skin has healed completely with no lasting issues and no scarring. During a telephone interview on 01/22/25 at 4:37 PM, CNA4 was asked about the incident when R96 was burned from hot water. CNA4 stated R96 had asked her to make her a cup of coffee. CNA4 stated she heated the water in the microwave in the nourishment room in another cup for about three minutes. CNA4 stated she returned to R96's room with the water, poured it in R96's cup, and while she was placing the lid on the cup, it spilled. CNA4 stated R96 felt the hot water sensation and screamed. CNA4 stated she immediately got the nurse who was in the hall. The nurse assessed R4's skin, undressed R96, and immediately applied cooling treatment on the skin. CNA4 stated she then reported the incident to the DON. CNA4 stated the facility conducted training on the use of the microwave and the aides cannot use the microwave. CNA4 stated water could only be heated by the nurse thirty seconds at a time and a thermometer must be used to measure the temperature. CNA stated she was not aware of other residents getting burns from hot liquids. During an interview on 01/23/25 at 8:10 AM, Registered Nurse (RN)1 was asked about the facility's policy for heating liquids in the microwave. RN1 stated only the nurses could heat something in the microwaves. RN1 then opened the nourishment room on station two that stored the microwave. The microwave was observed with signs posted with instructions that included Microwave Safety Until further notice the microwaves in Dining room and nourishment rooms are not to be used by staff and they have been taken out of service. Please read attached policies on microwave safety and use and storage of food brought in by residents and visitors. Complete Quiz and sign attestation indicating that you have read and understand the policies and directions for using a microwave. This education is mandatory. It is to promote safe practice and reduce risk of injury. Any questions please see a member of management. During a follow up interview on 01/23/25 at 9:41 AM, the DON confirmed only a nurse could heat up food and beverages for residents, and the microwaves available for staff to heat resident food and beverages were in the nourishment rooms on stations one and two. The facility provided documentation staff training on microwave safety occurred on 10/05/24, a performance improvement plan was implemented, and the surveyor observed safety signs and the microwave policy in place on 01/22/25. The surveyor confirmed training and policy implementation with staff interviews. On 01/23/25 at 12:31 PM, R96 was asked if she had staff heat water for her since the accident. R96 stated, No. R96 again declined her skin to be observed. This was determined to be past non-compliance with a verified compliance date of 10/5/24. 3. Review of R38's quarterly MDS, with an ARD date of 10/22/24 and located in the MDS tab of the EMR, revealed an admitted [DATE] and a BIMS score of three out of 15, indicating R38's cognition was severely impaired. It was recorded that R38 had one fall since admission with injury, and had diagnoses of Alzheimer's disease, anxiety, and unspecified dementia, severe, with mood disturbance. Review of R38's Nursing Quarterly Assessment, dated 06/12/24 and located in the EMR under the Assessment tab, revealed R38 was High Risk for falls, as indicated by a score of 16.0. Review of R38's investigation, dated 07/09/24 and provided by the facility, revealed, On 07/04/24 resident was found sitting on the fall mat with her back against her bed that was in the low position. Resident assessed at that time and no injury was noted and resident did not express any pain. On 07/05/24 bruising was noted to residents [sic] right thigh so an x-ray [high-energy electromagnetic radiation] of the right hip and femur was ordered. This x-ray showed no acute fracture. On 07/08/24 bruising was noted on resident's right knee. An x-ray was ordered of the right knee, femur, right hip, and right tibia and fibula. The mobile x-ray tech [technician] was only able to complete the x-ray of the right hip and pelvis. On 7/9/24 NP [nurse practitioner] assessed resident and noted swelling in her knee. The NP requested resident be sent to the ER [emergency room ] for evaluation due to the knee swelling. At the ER an x-ray of the right knee revealed a fracture of the lateral femoral condyle . An investigation was initiated and completed- Staff statements were completed and collected. Resident was last seen sitting up in her bed with her legs straight out on the bed and the over the bed table over her while she was eating dinner. The bed was in the lowest possible position to accommodate the over the bed table. The over bed table was placed on the left side of the bed. Staff noted the over the bed table had been pushed slightly towards the end of the bed when they found resident sitting on the floor. Residents [sic] legs were noted to be crossed with the left leg over top of the right. Due to resident's dementia, she was not able to be interviewed. Resident's roommate did not see resident fall. Resident is known to be fidgety and impulsive with poor safety awareness. At the hospital resident underwent an x-ray of right knee revealing a fracture of the lateral femoral condyle. Right hip x-ray was noted to be unremarkable. Pelvis x-ray showed no acute fracture. A CT [computed tomography scan] of the right knee was completed and revealed a displaced comminuted oblique fracture of the distal metaphysis. A CT of the head showed no acute fracture. A CT of the spine showed a C1 [upper cervical spine] fracture that was also noted back in 6/5/2023 so it is not acute. Resident currently remains admitted to the hospital- Hospital states resident is not a candidate for surgery and they are treating resident for pain and have splinted the fracture to immobilize. Care plan was reviewed, new intervention added to increase safety checks. Review of R38's Care Plan, revised 07/12/24 and located in the EMR under the Care Plan tab of the EMR, revealed, Resident is at high risk for falls: cognitive loss, lack of safety awareness, anxiety, ambulates with unsteady gait. The goal included, . The resident will not sustain serious injury through the review date . Interventions included to encourage the resident to participate in activities that minimize potential falls that provide diversion and distraction, keep the bed in low position, place a fall Mat on right side of bed, and increased safety checks. Review of R38's July 2024 TAR located in the EMR under the Order tab revealed Brace to Right lower extremity. skin check every shift. Maintain non weight bearing right lower extremity. every shift, order date 07/25/24 and discontinue date 09/23/24. On 01/20/25 at 11:36 AM, R38 was observed awake lying in a low bed talking nonsensical and holding a crayon. R38 was very fidgety and was noted to have a laceration on her forehead. The overbed table and a wheelchair were on the fall mat, leaving no space on the mat should R38 fall. On 01/21/25 at 8:49 AM, R38 was observed awake in a low bed dressed in pajamas with the lights off. R38's legs were pulled up to her chest, tugging up on her covers, and she was very fidgety. The fall mat next to R38's bed had an overbed table on top of the mat, leaving little space on the mat. On 01/22/25 at 9:54 AM, R38 was observed asleep in a low bed with covers up to her chin. The fall mat was in place with an overbed table and a wheelchair on the mat, leaving little room on the mat. During an interview on 01/22/25 at 10:57 AM, CNA2 was asked if R38 was a fall risk. CNA2 stated R38 does fall and stayed in her bed most of the time. CNA2 stated, [R38] can stand and that's when she falls. CNA2 stated when R38 was trying to get up from her low bed, they put her in the wheelchair and took her to the nurses' station so staff could keep an eye on her. On 01/23/25 at 7:28 AM, R38 was observed asleep in bed with the head of the bed up and the overbed table on top of the fall mat. During an interview on 01/23/25 at 8:52 AM, the DON and Regional Director of Nurses (RDON) were asked about R38's fall on 07/04/24. The DON stated it was unwitnessed, but later R38 complained of pain and a bruise was noted. The DON stated the first and second x-rays at the facility revealed no fracture, but R38 was still complaining of pain. She stated R38 was sent to the hospital where another x-ray revealed a fracture. The DON stated the origin of the injuries were unconclusive, stating staff were just in R38's room and the bed was in a low position with the fall mat in place. The DON stated it was possible the bedside table was nearby as R38 had just finished a meal and may have hit the base as she fell out of bed. The DON stated the plan of care was to have R38 in a low bed with fall mats. The DON stated staff knew R38 was at increased risk for falls and when [R38] gets antsy staff are to get R38 dressed and up in her wheelchair. The DON stated, Staff document by [R38]'s door to keep an eye on her. The DON stated R38 liked to color so staff should give her coloring activities to occupy her. The DON was asked if the overbed table should be on the fall mat between meals, obstructing the purpose of the mat. The DON stated, No. The DON was informed that the overbed table and wheelchair had been noted on R38's fall mat while R38 was in bed during the days of the survey. The DON was asked why R38 was always in bed and at times very fidgety. The DON stated nursing should be getting R38 out of bed and providing activities to occupy her such as coloring. The DON stated R38 was constantly in movement due to anxiety and her medication had been changed on the 12/24/24 and 01/07/25. The DON stated since R38's medication changes she still had the urge to get up out of bed and had high anxiety. The DON stated they were to make the environment safe in her room to prevent injury should R38 fall. The DON stated the placement of the overbed table was important. During an observation on 01/23/25 at 4:05 PM, R38 was observed in a low bed with a fall mat in place. The bedside table and wheelchair were on the mat, allowing little space on the mat should R38 fall. During an observation in R38's room on 01/23/25 at 4:07 PM, the Assistant Director of Nurses (ADON)was asked about the fall mat being obstructed with the overbed table and wheelchair. The ADON confirmed the overbed table and wheelchair should not be on the mat in case R38 fell as R38 could fall on the equipment. During a telephone interview on 01/23/25 at 5:52 PM, Licensed Practical Nurse (LPN)5 was asked about R38's fall on 07/04/24 and her fracture. LPN5 stated R38 was found on the floor on the fall mat but she did not see her fall. LPN4 stated R38's bed was in the low position and the fall mat was in place. LPN5 went on to say R38's plan to decrease falls included a low bed and a fall mat, and when R38 was restless staff would sit by her doorway and talk with her or get her up in the wheelchair. During a telephone interview on 01/23/25 at 5:59 PM, CNA7 was asked about R38's fall on 07/04/24. CNA7 stated she could not remember all the details but R38 was in a low bed and the fall mat was in place. CNA7 stated she thought the overbed table was in the way on the fall mat. CNA7 was asked what was in place to reduce R38's fall or injury. CNA7 stated all the staff took turns keeping an eye on R38 and keeping her in a low bed and fall mats next to her bed. CNA7 stated they were educated on R38's safety, saying, It's important to keep the mat clear of objects. During a telephone interview on 01/23/25 at 6:13 PM, RN2 was asked about R38's fall in 07/04/24. RN2 stated she could not remember exactly as it had been a while and she did not see R38 fall. RN2 asked what interventions were in place to reduce falls. RN2 stated R38 was in a low bed, had a fall mat, and they anticipated her needs. RN2 stated when R38 was restless, a CNA would sit close to her or inside the room when she was in bed, and R38 did sit in her wheelchair at times.

Based on observation, interviews, and facility policy review, the facility failed to ensure cold storage units contained interior temperature gauges, kitchen floors and walls were kept clean and in good repair, and leftovers were cooled down correctly, in one of one kitchen. This deficient practice had the potential to affect 107 of 107 residents who received meals prepared in the facility. This failure had the potential to affect the spread of food borne illness. Findings include: Review of the facility's policy titled, Sanitation Inspection, revised 03/29/23, revealed It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements. 4. Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily. Review of the United States Food & Drug Administration Food Code 2022, dated 01/18/23 and located at https://www.fda.gov/media/164194/download?attachment, revealed 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 C (135 F [Fahrenheit]) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. During the kitchen tour on 01/20/25 at 10:45 AM with the Dietary Manager (DM), the following observations were made: 1. The walls throughout the kitchen contained a collection of dried splatters, notably in and around the coffee and tea station, the range, the hand sink, along the lower walls at the reach-in refrigerator, and under the dish machine. An accumulation of food and dust debris was noted along the wall strips and on and around electrical switches. The strips along the lower walls were broken and an accumulation of a dark substance was noted at the wall tile and floor junctures. The door frames were gouged, exposing raw wood. 2. Four cold storage units did not contain a temperature gauge inside. These units included the first reach-in refrigerator located in the food storage room storing produce, the reach-in freezer storing ice cream, the reach-in freezer with vegetables, and the milk box in the food storage room. 3. The second reach-in refrigerator located in the food storage room was observed to have containers of pureed scrambled eggs, regular scrambled eggs, and link sausage. The DM stated these containers were leftovers from 01/20/25 at breakfast and they were taken off the steamtable at 8:00 AM. The DM was asked to take the temperature of the leftovers. The containers of pureed scrambled eggs measured 96 degrees F, regular scrambled eggs measured 86 degrees F, and link sausage measured 75 degrees F. The DM was asked if he was aware the temperature of the leftovers should be at 70 degrees F within two hours. However, two hours and 45 minutes had lapsed, and the temperatures were greater than 70 degrees F. The DM stated, Yes, they use ice baths to cool foods, but not today due to short staff. The DM then placed the containers back into the refrigerator. 4. On 01/22/25 at 8:32 AM, the walls were again observed throughout the kitchen containing a collection of dried splatters, notably in and around the coffee and tea station, the range, the hand sink, along the lower walls at the reach-in refrigerator, and under the dish machine. An accumulation of food and dust debris was noted along the wall strips and on and around electrical switches. The strips along the lower walls were broken and an accumulation of a dark substance was noted at the wall tile and floor junctures. The door frames were gouged, exposing raw wood. The DM was asked about the walls and tile build-up. The DM stated the kitchen was responsible for the walls but housekeeping and maintenance were responsible for the tile and floors as they have the proper tools to scrape off the build-up, but the kitchen staff only had a mop. The DM was asked for a working copy of the kitchen's cleaning schedule. The DM stated, it's not posted this week. The DM was asked to provide a copy of what the kitchen was to use. The DM then searched on his computer for a copy and was unable to locate it. 5. On 01/22/25 at 8:42 AM, a pan of ice was observed with three containers of food on top of the ice. The Dietary Assistant Account Manager (DAAM) stated the food was from 01/22/25 at breakfast. These included a pan of sausage, regular scrambled eggs, and pureed scrambled eggs which were 10 inches full and warm to touch. The DAAM was asked about the full container of eggs and would the temperature get to 70 degrees F in two hours. The DAAM stated, Yes. On 01/22/25 at 11:35 AM, a follow-up was conducted on the leftovers. The DM was asked to take the temperature of the pureed eggs in the 10-inch container. The pureed eggs measured 93.5 degrees F. The DAAM stated the eggs were taken from the steam table at 7:50 AM on 01/22/25. However, three hours and 45 minutes had lapsed, and the temperatures were greater than 70 degrees F. 6. During an interview on 01/23/25 at 1:48 PM, the Registered Dietitian (RD) was asked about the incorrect cooling down of leftovers observed on 1/20/25 and 1/22/25. The RD stated she wasn't told that the leftovers were incorrectly cooled down and weren't in a shallow pan. The RD asked what her expectation was for the kitchen to cool down leftovers. The RD stated, the kitchen shouldn't have any leftovers but if they do, they should be in a shallow pan as that's the way to cool it down the fastest. The RD was asked about the kitchen walls and floors in need of cleaning. The RD stated she identified dirty and stained walls in her last monthly sanitation report and confirmed they needed thorough cleaning.

Based on interview, record review, and facility policy review, the facility failed to ensure the Antibiotic Stewardship Program was consistently implemented. The facility failed to document criteria for the use of antibiotics, antibiotics used, and results of culture and sensitivity testing. The facility failed to analyze antibiotic stewardship data to plan process improvements. This failure placed all 111 of 111 residents at risk for adverse events related to administration of antibiotics. Findings include: Review of the facility's policy titled, Antibiotic Stewardship Program, dated 08/02/24, indicated, . Antibiotic Use Protocols. i. Nursing staff shall complete an SBAR [Situation, Background, Assessment, Recommendation] noted to notify the physician. ii. Laboratory testing shall be in accordance with current standards of practice. iii. The facility uses updated McGeer criteria to define infections. iv. The Loeb Minimum Criteria is used to determine whether to treat an infection with antibiotics. V. All prescriptions shall specify the dose, duration and indication for use. b. Monitoring Antibiotic use. i. Monitor response to antibiotics, and lab results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g.an antibiotic time-out). ii. Antibiotic orders obtained on admission, whether new or readmission, to the facility should be reviewed for appropriateness. iii. Antibiotic orders obtained on admission from consultants, specialty, or emergency providers shall be reviewed for appropriateness. iv. Monitor during each monthly medication review when the resident is prescribed antibiotics v. Random audits of antibiotic prescriptions for shall be performed to verify completeness and appropriateness. vi. At least one outcome measure associated will be tracked monthly as prioritized by the infection control risk assessment or other surveillance data . The protocols indicated the Infection Preventionist, Administrator and Physicians were responsible for implementing the Antibiotic Stewardship program. During an interview on 01/23/25 at 10:45 AM, the Infection Preventionist (IP) stated the facility maintained a monthly line listing of the resident infections. When asked how IP received information about antibiotic use, she stated they got notified if an order for antibiotics was initiated. When asked about monthly summary reports, the IP explained she was new to the facility and the role of IP and would ask the former IP who was now the Director of Nursing (DON). The DON stated she had completed monthly summaries of the line listings. When asked if they kept any floor plans that identified the location of the infections treated (to observe for clusters or trends) the DON and IP reported they did not. The DON then provided six months of logs and monthly summaries. Review of the January 2025 Monthly Infection Surveillance Log (MISL), revealed 12 of 22 entries on the log identifying the residents were treated with antibiotics; however, the data was incomplete. Missing information included if the criteria for the definition of an infection was met (McGeers), the name of the antibiotic that was administered, and/or the results of culture and sensitivity testing (to ensure the antibiotic would be effective). Review of logs dated September 2024 through December 2024, revealed a pattern of missing data. Review of the December 2024 Monthly Infection Surveillance Summary Report (MISSR) Page 1 showed the percentage of patients with an infection was 18.8%. There was no documented evidence that the facility used data from the MISL or MISSR to analyze trends or patterns or to identify potential areas for improvement. During an interview on 01/23/25 at 3:30 PM, the IP confirmed the missing data on the MISL.

Based on observation, record review, and interview, the facility failed to 1.) complete wound care in a manner to prevent cross contamination for one of one resident (Resident (R) 78) reviewed for wound care out of a total sample of 32, and 2.) wear the proper Personal Protective Equipment (PPE) when entering into a contact isolation room for one of 27 residents (room [ROOM NUMBER]) noted to be COVID positive. These failures put the vulnerable population of residents at greater risk of developing infections and the increased risk of staff spreading infections throughout the facility by not adhering to the isolation precautions. Findings include: 1.Review of R78's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), revealed R78 was admitted to the facility on [DATE] with diagnoses of dementia, chronic obstructive pulmonary disease, and chronic kidney disease. Review of R78's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 11/14/24, revealed R78 was at risk for developing a pressure ulcer. It was recorded R78 had a Brief Interview for Mental Status (BIMS), score of three out of 15, which indicated the resident was severely cognitively impaired. Review of R78's Care Plan, located under the Care Plan tab in the EMR and dated 12/31/24, indicated, . The resident [R78] has open [sic] area on his sacrum r/t [related to] incontinence/ immobility . Interventions were, . Assess characteristics of wound, including color, size (length, width, depth), drainage, and color. Low air mattress at 200 [sic]. Monitor site of impaired tissue integrity for color changes, redness, swelling, warmth, pain, or other signs of infection. Provide skin tissue care as needed . Review of R78's Physician Orders, located under the Orders tab in the EMR and dated 01/16/25, revealed, . Sacrum Stage 3 [sic]. Cleanse with NS [Normal Saline], apply medical grade honey, cover with bordered gauze daily and PRN [as needed] [sic] . During the wound care observation on 01/22/25 at 3:20 PM, Registered Nurse (RN) 2, the following failures were noted with wound care: 1) RN2 sprayed Saline Wound Cleanser to a clean 4x4 gauze pad and then patted all areas of the wound bed with the same 4x4. 2) RN2 applied the medical grade honey to the wound bed with a clean Q tip. As she was applying the honey, a small amount of honey dropped to the intact skin below the wound. RN2 took the Q tip and pushed the honey into the wound bed. 3) During the wound care observation, the front of RN2's gown came down to the breast area, exposing RN2's uniform. The theRN2 right arm sleeve of the gown came off her shoulder and was down to the elbow area of RN2. This also exposed RN2's uniform. 4) RN2 brought the spray bottle of saline wound cleanser out of R78's room and placed it back into the bottom drawer of the wound cart without first cleaning the bottle. During an interview on 01/22/24 at 3:50 PM, RN2 stated, I should have fastened the top of my gown before I started the wound care so it wouldn't slide down. I should have also cleaned the bottle of saline wound cleanser with a disinfectant wipe before putting it in the bottom of the wound cart. When asked if RN2 all areas of the wound bed should have been wiped with one 4x4, RN2 stated, No, I should have gotten a new one before I wiped it the second time. RN2 was asked if she should have pushed the honey from the skin below the wound to the middle of the wound bed, and she replied, I didn't think it was dirty. During an interview on 01/23/25 at 12:08 PM, the Director of Nursing (DON) stated, I expect the nurse to clean the wound bed using a circular motion with one 4x4 then discard it and then get a clean 4x4 to clean the wound bed again. [R78] was positive for COVID so nothing should have been brought out of his room that the nurse took into the room for wound care. The nurses' gown should have been fastened at the top to prevent her scrubs from getting contaminated due to the resident having COVID. During an interview on 01/23/25 at 5:11 PM, the Infection Preventionist (IP) stated, The nurse's gown should have been tied at the top or the strap placed over her head so the gown would not slide down. The nurse should clean the wound in a circle, getting a clean 4x4 each time this is done. The saline wound cleanser should not have been brought out of the resident's room because he [R78] is in contact isolation. 2. During an interview on 01/20/25 at 9:45 AM, the Director of Nursing (DON) reported the facility currently had 27 residents who were in droplet precautions after testing positive for the COVID virus, or who had close contact with a resident who tested positive. On 01/20/25 at 11:28 AM, Housekeeper (HSK) 1 went into room [ROOM NUMBER] to clean the room. Posted on the room's door frame was a sign indicating droplet precautions were in place. The sign directed staff to sanitize their hands and don a gown, gloves, N95 mask, and an eye shield prior to entering the room and to discard them prior to leaving the room. HSK1 entered room [ROOM NUMBER], wearing an N95 mask and gloves. No gown or face shield were used. While cleaning the room, HSK1 exited the room twice while wearing gloves and the N95 mask, took several steps to the cart, and replaced or obtained cleaning supplies without discarding the N95 mask and gloves or completing hand hygiene. During an interview on 01/20/25 at 11:40 AM, HSK 1 acknowledged the error and stated the guidelines posted outside the room should have been followed.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 113) reviewed for communication out of a total sample of 32 was communicated with in a language the resident could understand. R113 was Spanish speaking only, and the lack of providing communication in the resident's language could potentially cause frustration and possible unmet care needs. Findings include: Review of facility's policy titled, Communicating with Persons with Limited English Proficiency, dated 03/14/23, revealed It is the policy of this facility take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs, and other benefits. The purpose of this policy is to ensure meaningful communication with LEP residents. Review of R113's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R72 was admitted on [DATE] with diagnoses of unspecified fracture of right femur, repeated falls, and dementia. Review of R113's admission Minimum Data Set (MDS), located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 12/22/24, revealed the resident was unable to complete the interview, was rarely understood, and was severely cognitively impaired. It was recorded that R113 required maximum assistance with mobility and was dependent on toileting and hygiene. Review of R113's Recreation Comprehensive Assessment, located in the EMR under the Assessment tab and dated 12/22/24, revealed, [Resident name] speaks Spanish. Her answers in Spanish are not always appropriate r/t [related to] cog[nitive] impairment. Prefers tv cartoons and classic Spanish music. [Resident name] may benefit from accommodations for communication. Review of R113's Progress Notes, located in the EMR under the Progress Notes tab, dated 12/18/24, and documented by nursing staff, revealed, . [R113] speaks Spanish. Reason for visit: The resident is being evaluated today for a new admission . Staff Spanish to English interpreter utilized during exam . During a continuous observation on 01/21/25 at 9:06 AM until 10:14 AM, R113 was observed sitting in her Geri-chair at the nurses' station, swinging her legs out of her chair, and speaking in Spanish. Throughout the observation, Registered Nurse (RN) 4 was observed three times assisting R113 by placing her legs back into the chair. RN4 only spoke to R113 in English. The Social Services Director (SSD) walked by R113 twice and did not approach the resident, and the Director of Nursing (DON) walked by R113 once and did not approach the resident. Certified Nurse Aide (CNA) 6 approached R113, attempted to adjust R113's legs in her chair, and spoke to her in English. During an interview on 01/21/25 at 9:06 AM, CNA6 stated staff used the translation line or the resident's family member to speak to R113. She stated there were also staff that spoke Spanish so occasionally they would get them to help. She stated usually R113 just slept and was never like this [restless and agitated]. During an interview on 01/21/25 at 9:11 AM, RN8 and RN4 stated R113 had no safety awareness and was a fall risk. They stated the family member encouraged them to call. RN8 stated, We can use the language line, and we have some staff that speak Spanish. During an interview on 01/22/25 at 8:52 AM, the DON and the Administrator stated the care plan should have been followed, the language line should have been contacted, and a snack should have been offered to R113. The Administrator stated that he had placed a sign at each nurses' station with the language line number to ensure staff could call when necessary. He stated prior to this it had been difficult to see the numbers. The sign was observed at each station. During an interview on 01/23/25 at 8:40 AM, the SSD stated that since R113 had a communication barrier, staff would usually contact R113's family member and use the language line. She stated she had walked by the resident twice on 01/21/25 and noticed she was agitated. The SSD stated she did not stop because she saw the nurses working with her and she did not want to interrupt what they were doing. She stated she was responsible for developing care plans for resident communication. During an interview on 01/23/25 at 12:21 PM, the DON stated when the SSD walked by staff talking with R113 in English, she should have asked staff what they had done to help R113 and offered her assistance.

Based on observation, interview, record review, and policy review, the facility failed to ensure two residents (Resident (R) 24 and R82) of 32 sampled residents were free from physical abuse from R90, when R90 punched R24 and R82. The abuse caused by R90 had the potential to cause harm to all current residents throughout the facility. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation Policy and Procedure, dated 09/12/24, revealed, The facility strictly prohibits abuse, mistreatment, neglect, or exploitation of all resident, or misappropriate of resident property . The facility will protect residents from harm during an investigation by: immediately removing the alleged perpetrator from resident care areas . 1. Review of R24's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R24 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease and delusional disorders. Review of R24's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 11/20/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating R24 was moderately cognitively impaired. Review of R24's Progress Note, located under the Progress Note tab of the EMR and dated 08/31/24, revealed, . CNA reported to nurse that she observed [R90] punching [R24] in [the] courtyard. [R90] informed writer that he was trying to get [R24] out of his way but does not remember hitting him. [R90] mentioned that [R24] did not hit him. [R90] refused skin assessment. Skin tear observed at back of [R24] left hand [bruising around area] and skin tear on right side of forearm. Denies pain. Moves all extremities. No further injury observed. Neurological checks initiated . During an attempted interview on 01/20/25 at 1:00 PM, R24 refused to speak about the incident. 2. Review of R82's Admission Record, located under the Profile tab of the EMR, revealed R82 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses that included dehydration and type 2 diabetes. Review of R82's quarterly MDS, located in the EMR under the MDS tab and with an ARD of 12/30/24, revealed the resident had a BIMS score of 15 out of 15, indicating R82 was cognitively intact. Review of R82's Care Plan, located under the Care Plan tab in the EMR and dated 01/02/25, revealed, Resident is/has potential to be verbally aggressive. The goal was resident will demonstrate effective coping skills through the review date. Interventions included, . Administer medication as ordered, assess and anticipate resident's needs and assess resident's understanding of the situation . Review of R82's After Visit Summary, dated 09/17/24 and provided by the facility, revealed . [R82] was evaluated in the emergency room . Reason for visit: Facial Injury . Diagnoses: Orbital contusion, left, initial encounter, Assault, Contusion of lip, initial encounter, conjunctival hemorrhage of left eye . During an interview on 01/20/25 at 1:50 PM, R82 stated he was laying in his bed with the television on. He stated R90 asked him to turn off the television and he said no. R82 stated R90 said he would come over and turn it off. R82 stated he did not turn it off so R90 came over and threw the overbed table on the bed and then R90 jumped on top of him while he was in bed and started punching him. R82 said R90 then ran out into the hall and started telling staff what he had done. 3. Review of R90's Admission Record, located under the Profile tab of the EMR, revealed R90 was initially admitted on [DATE] with diagnoses that included vascular disease and bipolar disorder. Review of R90's quarterly MDS, located in the EMR under the MDS tab and with an ARD of 01/06/25, revealed the resident had a BIMS score of 15 out of 15, indicating R90 was cognitively intact. Review of R90's Care Plan, located in the EMR under the Care Plan tab and initiated on 08/31/24, revealed, The resident is/has potential to be physically aggressive r/t (related to) poor impulse control. The goal was for the resident not to harm self or others through the review date. Interventions included, . administer medications as ordered, give the resident as many choices as possible, psychiatric/psychogeriatric consult as indicated and resident to have 1:1 supervision from 7:00 AM to 11:00 PM . During an interview on 01/20/25 at 10:30 AM, R90 stated he was depressed and was not sure why he had someone in his room all the time. R90 was asked about the incidents involving R24 and R82. R90 stated he did not remember any incidents. During an interview on 01/20/25 at 1:30 PM, Certified Nurse Aide (CNA) 6 stated that she knew R90 had one to one supervision several times since he readmitted to the facility in October. She stated he would be on one-to-one supervision and then off again. CNA6 stated she thought this was his last time and stated, If he hits anyone else, then he will be discharged . During an interview on 01/21/25 at 9:17 AM, Registered Nurse (RN) 8 stated R90 was always on one-to-one supervision, and the staff providing the supervision should always be with him. RN8 stated the first incident with R90 was when R90 hit R24 because he was going too slow outside. She stated the one-to-one supervision was from 7:00 AM until 11:00 PM and then he had a motion sensor alarm that was plugged in at the desk. During an interview on 01/21/25 at 6:55 PM, the Administrator stated that R90 punched R24 on 08/30/24 as they were going outside to the smoking area, and after that, R90 was placed on 30-minute checks and was moved to a private room. He stated there were no incidents so he was moved to a semi-private room with R82 but remained on 30-minute checks. He stated on 09/17/24, R90 punched R82 after they were in an altercation about R82's television. The Administrator stated R82 went to the emergency room and R90 went to a behavioral health hospital. He stated when R90 returned on 09/24/24, he was moved into a private room and was placed on one-to-one supervision. During an interview on 01/22/25 at 8:52 AM, the Director of Nursing (DON) and the Administrator stated R90 should always have one-to-one supervision from 7:00 AM until 11:00 PM and then he had a motion sensor alarm from 11:00 PM until 7:00 AM. The Administrator and the DON stated there had been no further incidents.

Based on record review, interview, and facility policy review, the facility failed to report an allegation of abuse within two hours to the state agency for one of seven residents (Resident (R) 71) reviewed for abuse out of 32 sampled residents. This had the potential to affect all the residents in the facility who were at risk of abuse. Findings include: Review of R71's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R71 was admitted to the facility on [DATE] with the diagnoses of diabetes mellitus, transient ischemic attack (TIA), and major depressive disorder. Review of R71's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 08/17/24 revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated R71 was severely cognitively impaired. Review of R71's Care Plan located under the Care Plan tab in the EMR, dated 10/17/22, revealed The resident has a behavior problem: agitation, cursing, using derogatory language and expressing frustration/anger at others [sic]. The interventions that were in place included Anticipate and meet the resident's needs. Divert attention by giving resident alternative objects and/or activites [sic]. Familiarize with belongings/surroundings. Listen to and attempt to calm. Psych [psychiatric] eval [evaluation] with [name of psychiatric services]. Remove resident from environment. UA CNS [urinalysis culture and sensitivity]. R71 was also care planned for false accusations toward staff i.e. stating staff is providing care. Review of R71's Nursing Progress Note located under the Progress Note tab in the EMR, revealed a noted dated 09/12/24 at 9:10 PM which stated, Monitor behaviors r/t [related to] agitation, cursing, using derogatory language and expressing frustration/anger at others. Every shift [sic] Was a behavior observed? Yes [sic] Resident was disrespectful to nurse using derogatory language when administering medication. Resident states he will not take any medications until he speaks to the doctor. And asked us to get out of his room with CNA [Certified Nursing Assistant] as witness. During a phone interview on 01/23/25 at 10:14 AM, Registered Nurse (RN) 5 stated, I went into the room because his [R71] call light was on. He [R71] was requesting shoulder rub to his shoulder and that was when he [R71] told me the nurse came in to give me my medicines and he [R71] refused it. Then the nurse gave him the middle finger. There was an aide in the room with the nurse so with the past behaviors I didn't think this was abuse. I talked to the nurse and the aide about it. The nurse said she didn't do that, and the aide said the same thing to me. RN5 was asked who she reported this to, and RN5 stated, I didn't until the DON [Director of Nursing] asked me about it and I told her [DON] what I knew. RN5 was asked if there was a report of abuse whether it be any kind of abuse, what was the reporting time frame for her [RN5] to report. RN5 stated, I would report this immediately to my supervisor. But in this situation of the resident cursing and refusing his meds in the past, I didn't think it was abuse and I didn't report it. During an interview on 01/23/25 at 11:57 AM, the DON stated, [R71] reported to the day shift nurse [Licensed Practical Nurse (LPN) 1] on 09/13/24, the nurse the night before had given him the middle finger after he had refused to take his medications. During the investigation of this allegation, it was discovered that [RN5] was told by [R71] of this incident occurring on 09/12/24 after the incident occurred with the night nurse giving him [R71] the middle finger. The DON began reviewing the statement from RN5 and stated, [RN5] talked with the resident, the night nurse and the CNA because the night nurse had taken the CNA into the resident's room with her. They both reported that the night nurse left the resident's room with one cup of pills in one hand and a cup of water in the other hand. The night nurse and the CNA confirmed [R71] was being verbally abusive towards them telling them to get out. The DON was asked when staff should report any kinds of alleged abuse. The DON stated, They are to report this to me immediately and then we have two hours to report it to state. During an interview on 01/23/25 at 6:10 PM, the Administrator stated, We have drilled down to our managers and staff, they are to report any allegation of abuse immediately even if there is a witness, no matter if there is a history of the residents or what they do. So, we can report this to the state within two hours. Review of the facility's policy titled, Abuse, Neglect, Exploitation, dated 09/14/24, revealed Notify the appropriate agencies . In the case of abuse or serious bodily injury, no later than 2 [sic] hours after discovery or forming the suspicion .

Based on interview, record review, and facility policy review, the facility failed to provide written notification of a hospital transfer to the resident and responsible party (RP) for one of five residents (Resident (R) 62) reviewed for hospitalization of 32 sample residents. The failure had the potential to affect the residents and/or their representatives concerning the reason for the transfer and the resident's appeal rights. Findings include: Review of the facility's policy titled, Transfer or Discharge Notice, updated 01/19 and provided by the facility, revealed 3. The resident and/or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge . Review of R62's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 12/30/24 located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE] and a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R62's cognition was intact, and had diagnoses of diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. Review of R62's General note, dated 09/09/24 and located in the EMR under the Progress Note tab, revealed Resident sent to [name] hospital. Report called to [name] by [company] nurse per her request. Resident transported via stretcher with EMS [emergency medical services]. Resident was sent with cell phone, tablet, art book, colored pencils, headphones, wallet. Bed hold notice signed and sent with patient. Left message with emergency contact. Awaiting return call. Review of R62's Medication Administration Note, dated 09/10/24 and located in the EMR under the Progress Note tab, revealed R62 was hospitalized . Review of R62's Transfer Form, dated 09/09/24 and located in the EMR under the Assessment tab, revealed the reason for the transfer was due to a low K [potassium] 2.1 and R62's [family member] was telephoned about the transfer to the hospital and the reason for the transfer. Nothing was documented that written notice was provided to R62 and/or R62's family member. Review of R62's Notice of Hospital Transfer, dated 09/09/24 and provided by the facility, revealed A copy of this notice is being provided to the following persons and organizations: 1. You and/or your representative, guardian, or any other individual known to have acted as your agent and/or representative, 2. Notice to your local Ombudsman .Please ask your nurse to notify me if you do not agree with your discharge so that I can meet with you to discuss your options. I want to ensure that you are comfortable with your discharge plan and ensure that complete [facility name] provides you with your options for continued care if needed. There was no documentation indicating the form was provided to R62. During an interview on 01/22/25 at 9:39 AM, R62 was asked if she had gone to the hospital. R62 stated, Yes, several times, last time was few months ago. R62 was asked if she had been given any papers for her transfer to the hospital for her recent hospitalization . R62 stated, No she had not been given a transfer paper. During an interview on 01/22/25 at 10:06 AM, the Assistant Director of Nursing (ADON) was asked if R62 received a written transfer notice when R62 was transferred to the hospital on 09/09/24. The ADON stated R62 was not provided with a paper copy of the transfer notice. During an interview on 01/22/25 at 10:23 AM, the Director of Nursing (DON) provided a hard copy of the transfer notice when R62 was sent to the hospital. The DON stated the notice was placed in the transfer packet that was given to EMS to give to the hospital. The hospital then should have given the copy of the notice to R62. The DON could not verify that a written copy of the notice was provided to R62. The DON confirmed R62 was her own representative.

Based on interview, record review, and facility policy review, the facility failed to provide written notification of the bed hold policy to the resident and responsible party (RP) for one of five residents (Resident (R62) reviewed for hospitalization of 32 sample residents. The failure had the potential to affect the residents planning on returning to the facility. Findings include: Review of the facility's policy titled, Bed-Hold and Returns, updated 10/19, revealed Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Review of R62's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 12/30/24, located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE] and a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating R62's cognition was intact, and had diagnoses of diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. Review of R62's General note, dated 09/09/24 and located in the EMR under the Progress Note tab, revealed Resident sent to [name] hospital. Report called to [name] by [company] nurse per her request. Resident transported via stretcher with EMS [emergency medical services]. Resident was sent with cell phone, tablet, art book, colored pencils, headphones, wallet. Bed hold notice signed and sent with patient. Left message with emergency contact. Awaiting return call. Review of R62's Medication Administration Note, dated 09/10/24 and located in the EMR under the Progress Note tab, revealed R62 was hospitalized . Review of R62's Bed Hold Notice, dated 09/09/24 and provided by the facility, revealed The notice is presented to you because of the following: Admission to the hospital. The notice fulfils requirements to remind you of this facility's bed hold policy (see attached). Please read carefully and indicate whether or not you wish to reserve your room. The notice was signed by R62 but did not indicate the form was provided to R62. During an interview on 01/22/25 at 9:39 AM, R62 was asked if she had gone to the hospital. R62 stated, Yes, several times, last time was few months ago. R62 was asked if she had been given any papers for a bed hold for her recent hospitalization . R62 stated, No she had not been given a bed hold paper. During an interview on 01/22/25 at 10:06 AM, the Assistant Director of Nursing (ADON) was asked if R62 received a written bed hold notice when R62 was transferred to the hospital on 09/09/24. The ADON stated R62 was provided with a paper copy of the bed hold which was uploaded in the EMR. The ADON then reviewed the EMR, and no bed hold notice was found. During an interview on 01/22/25 at 10:23 AM, the Director of Nursing (DON) provided a hard copy of the bed hold with R62's signature, dated 09/09/24, when R62 was sent to the hospital. The DON stated the notice was placed in the transfer packet that was given to the EMS to give to the hospital. The hospital then should have given the copy of the notice to R62. The DON could not verify that a written copy of the notice was provided to R62. The DON confirmed R62 was her own representative.

Based on interview, record review, and review of other documentaion as indicated, it was determined that for one (R211) out of one resident sampled for hospitalization , the facility failed to complete a comprehensive respiratory assessment, monitor, and provide respiratory interventions for a resident recognized as having an acute change in respiratory status. R211 was caused further distress when she remained without supplemental respiratory interventions (oxygen) until EMS (Emergency Medical Services) implemented interventions upon arrival at the facility. For one (R8) out of one resident reviewed for potential for constipation, the facility failed to assess the residents for signs or symptoms of constipation and administer medications as ordered for no bowel movement (BM) after three (3) days. For one (R34) out of six residents reviewed for unnecessary medications, the facility failed to follow Physician's orders to monitor for sedation with the usage of Melatonin. Additionally, the facility failed to obtain weights as per Physician order for one (R66) out of five residents reviewed for weight loss, which led to uncertainty of when R66's weight loss began. Findings include: A facility policy Acute Condition Changes - Clinical Protocol, adopted 11/2018 and last updated 10/2019 included: The nurse shall assess and document/report the following baseline information: - Vital signs; - Onset, duration, severity. 1. Review of R211's clinical record revealed: 7/1/21 - R211 was admitted to the facility with a history of a stroke, diabetes, difficulty swallowing, and a peg tube (feeding tube). 10/1/22- Review of the EMS (Emergency Medical Services) Patient Care Report revealed the dispatcher received a call at 3:52 PM from the facility to request an ambulance to transport a patient to the hospital. At 4:03 PM, EMS crew members arrived on scene at the facility and found R211 with a . room air oxygen saturation of 85% (normal blood oxygen saturation is 95-100%) and a blood glucose of 484 mg/dl (ADA recommendation for someone with diabetes 80-130) upon their contact, the patient is unresponsive, shallowed breathing, warm to the touch EMS placed a non-rebreather mask (enables delivery of high concentrations of oxygen) on R211. R211's response remained unchanged. 10/1/22 4:07 PM - A nurse progress note by E12 (RN) documented, Upon start of shift rounds at approx. 3:30 PM, observed patient with rapid respirations, unresponsive and diaphoretic (profuse sweating). R211's vital signs were as follows: blood pressure 168/77 (normal range for an adult is 120/80, 140/90 is high blood pressure); blood sugar 382 (high) temperature 98.2 Fahrenheit; pulse 144 beats per minute (normal range for an adult pulse is 60-100 beats per minute); respirations 24-28 breaths per minute (normal range for respirations [breathing] is 12-20 breaths per minute at rest). R211's clinical record lacked evidence that an oxygen saturation was obtained. The on-call E8 (NP) was notified and an order was obtained to transfer R211 to the hospital. 10/1/22 4:16 PM - A nursing progress note documented, R211 was transferred to the hospital via EMS. R211 had an abnormal heart beat was unresponsive. The facility lacked evidence of any monitoring or interventions until EMS arrived at the facility and EMS recorded a low oxygen saturation of 85% on room air. 10/1/22 (Untimed) - Hospital documentation included: . female with complicated past medical history brought to the emergency department by EMS with altered mental status.Patient was found unresponsive at the nursing facility satting (refers to oxygen saturation) at 85% on room air. Enroute to the ED (Emergency Department), EMS personnel attempted to intubate (place a plastic tube into the windpipe to maintain an open airway) R211 without success. Alternately, EMS initiated bag-valve-mask breathing. Upon arrival to the ED, R211 was successfully intubated (a breathing tube was placed), placed on a ventilator (a machine that breathes for you) and was admitted to the ICU (intensive care unit). 10/3/22 - A statement composed by E12 (RN) documented on September 30, 2022, patient's sister verbalized patient felt warm. E12 documented that R211 was in bed lying under thick, heavy, personal blanket. 12/8/22 12:50 PM - During an interview via telephone, E12 (RN) stated on the evening of 9/30/22 during her 3:00 PM - 11:00 PM shift, she recalled R211's family member approaching the nurses station and were concerned as R211 was warm to the touch. E12 stated that she went to assess R211 who was alert, but felt warm. E12 confirmed she did not take R211's temperature at that time and stated, I had no urgent concern at that time. E12 stated she worked the next day on 10/1/22 on the 3:00 PM-11:00 PM shift. The off going nurse did not report any concerns for R211. E12 confirmed that her observation and assessment of R211 revealed a significant change in condition; rapid respirations and a heart rate in the 140's. E12 stated she could not recall taking an oxygen saturation, but stated that it should have been part of her assessment. She further confirmed that no respiratory interventions were initiated such as supplemental oxygen administration and R211 was transferred out of the facility by EMS no later than 4:30 pm. 12/9/22 9:14 AM - During an interview, E13 (LPN) confirmed she was assigned to R11 on 10/1/22 7:00 PM - 3:00 PM shift. E13 did not obtain a temperature or a pulse ox. as R211 was alert and taken her meds. and was at her baseline. 12/9/22 9:40 AM - During an interview, E26 (LPN) confirmed he was assigned to R211 on 9/30/22 11:00 PM - 7:00 AM shift and at 12:41 AM R11's vital signs were as follows: pulse 78, respirations 18, temperature 97.8, pulse ox 96% room air, (no blood pressure documented). 12/9/22 9:48 AM - During an interview, E28 (LPN) confirmed she was assigned to R11 on 9/30/22 7:00 AM - 3:00 PM shift. Documentation lacked evidence of any vital signs obtained during that shift. 12/9/22 10:41 AM - During an interview, E29 (CNA) confirmed she was assigned to R211 on 9/30/22 3:00 PM - 7:00 AM 10/1/22. E29 confirmed that R211 did feel warm but stated it's always hot in that room because her room mate likes it hot. 12/9/22 11:03 AM - During an interview, E7 (UM) confirmed that per their facility policy following an acute change in condition, a comprehensive set of vital signs would include a pulse ox (same as oxygen saturation). Additionally, the clinical record lacked evidence that R211's pulse ox was obtained. Interviews of facility staff and review of facility documentation lacked evidence of a complete assessment of R211 on 9/30/22 on the evening shift when staff failed to complete a BP until after R211 was identified to have an acute change in respiratory status and EMS arrived on 10/1/22. The facility also lacked evidence of appropriate respiratory assessments and necessary interventions including the application of oxygen from when R211 was found at approximately 3:30 PM with rapid respirations, unresponsive and diaphoretic until the arrival of EMS at 4:03 PM. 12/9/22 - Findings were reviewed with E1 (NHA) and E4 (DON) during the Exit Conference, beginning at 2:14 PM. 20835 2. Review of R8's clinical records revealed: 7/19/21- R8 was admitted to the facility. 8/13/21 - The following Physician's orders were written for three laxative medications: - Milk of Magnesia (MOM) every 24 hours as needed for constipation to be given at bedtime if no BM in 3 days. - Dulcolax suppository every 24 hours as needed if no BM from MOM by the next shift. - Fleet Enema every 24 hours as needed if no BM Ducolax suppository within 2 hours. If no BM from Fleet enema, call MD/APP (Advanced Practice Providers) for further orders. 8/13/21 - A care plan for at risk for constipation related to decreased mobility was developed and implemented with a goal that R8 would have a normal BM every 3 days. The interventions included to follow the bowel protocol which included to monitor, document, and report signs and symptoms of constipation; monitor for change in mental status, including new onset of confusion and sleepiness; abdominal distention, vomiting, small loose stool, fecal smearing, bowel sounds, abdominal tenderness, fecal impaction; and to record BM pattern each day including the amount and consistency. 10/1/22 through 12/5/22 - The Bowel Report revealed there were a total of three (3) periods of time in which R8 did not have BM for greater than 3 days (more than 9 shifts) and there was lack of evidence that the facility assessed for signs or symptoms of constipation and/or administered medications as follows: - 10/2/22 night shift through 10/6/22 evening shift for total of 15 shifts. - 11/4/22 night shift through 11/9/22 night shift total of 16 shifts. - 11/15/22 evening shift through 11/21/22 day shift for total of 17 shifts. 12/7/22 1:59 PM - An interview with E5 (ADON) was conducted and the above findings were reviewed with E5 and confirmed. 40264 3. Review of R34's clinical record revealed the following: 9/17/22 - R34 was readmitted from the hospital to the facility with a hip fracture. 9/17/22 - R34's Significant Change MDS Assessment revealed that R34's cognition was intact. 9/17/22 - R34 had a Physician's order for Melatonin (naturally occurring hormone/dietary supplement that helps promote sleep) 3 mg tablet at bedtime for insomnia, hold for sedation and notify the NP (Nurse Practitioner) if held twice. 9/20/22 - R34 was care planned for the use of Melatonin related to insomnia. Interventions included to monitor and document side effects and effectiveness every shift. 12/7/22 - Review of R34's September 2022 through November 2022 MAR (Medication Administration Record) lacked evidence that R34 was monitored for sedation. Further review of R34's MAR revealed that it was initiated on 12/6/22 that R34 had a Physician's order to monitor side effects for the use of Melatonin with targeted behaviors including sedation. 12/8/22 4:00 PM - In an interview, E6 (IP) stated that R34 went to the hospital for a right hip fracture. E6 confirmed that on readmission, E34 was still receiving Melatonin 3 mg but the Physician's order for side effect monitoring including sedation was not put in the EMR (Electronic Medical Record) until 12/6/22. 4. Review of R66's clinical record revealed the following: The facility policy titled, Weighing the Resident/Patient, last revised 5/2021, documented, .Weights will be recorded .Protocol .C either monthly or more frequently .as ordered by the physician . 2/1/22 - R66 was admitted to the facility. 2/7/22 (revised 8/15/22) - R66 had a care plan developed for potential nutritional problem related to significant weight loss, therapeutic diet and variable intake of meals with interventions, including weight as per policy (2/7/22) and RD (Registered Dietitian) to evaluate and make diet changes and recommendations PRN (as needed) or when necessary (2/7/22). 3/3/22 - R66 had an active Physician's order for monthly weights. 5/10/22 - R66's quarterly MDS assessment revealed that R66 was able to eat and drink independently with set up help. R66 was receiving a diuretic medication (helps reduce the amount of water/excess fluid in the body) and had a weight of 205 lbs with no known weight loss. 5/10/22 - The facility's Nutritional Assessment, completed by E24 (RD), documented R66's weight obtained on 4/3/22 as 205.2 lbs. (pounds). E24 noted R66's nutrition evaluation as .Stable weight since admission with meals and outside sources .rec (recommend) 75%-100% of most meals to meet needs .maintain stable weight or allow for gradual weight loss .no nutrition problem. Review of R66's weight records from April 2022 through June 2022 revealed that on 4/3/22, R66 weighed 205.2 lbs. On 6/1/22, R66 weighed 186.2 pounds which was a 9.26 % significant weight loss. There was a lack of evidence that R66's May 2022 weight was obtained. 12/8/22 10:32 AM - When asked whether R66's weight information of 205.2 lbs on 4/3/22 was the same information documented on the 5/10/22 Nutritional and MDS Assessments, E24 (RD) confirmed and stated that R66's weight was not obtained in May 2022. E24 stated that the facility was not able to determine the time frame in May 2022 when R66 started losing weight. 12/9/22 9:30 AM - During an interview, E4 (DON) confirmed that R66's Physician's order for monthly weights was not done in May 2022. The facility failed to follow the Physician's order to obtain R66's weight for the month of May 2022. 12/9/22 - Findings were reviewed with E1 (NHA) and E4 (DON) during the Exit Conference, beginning at 2:14 PM.

Based on record reviews, interviews and review of other facility documentation it was determined that the facility failed to ensure that all residents were free from abuse when one (1) resident (R90) out of 45 sampled residents sexually abused multiple residents over a two month period. Ten (10) (R358, R308, R70, R11, R51, R18, R5, R43, R359, and R360) residents were touched sexually without their consent which resulted in an immediate jeopardy (IJ) risk to residents residing in the facility from (MONTH) to (MONTH) (YEAR). This IJ is past non- compliance. Findings include: The facility's policy on Abuse Prohibition last revised 11/28/16 states that: Sexual abuse is any non-consensual sexual contact of any type with a resident. CMS definition and guidance on abuse includes: Sexual Abuse Sexual abuse is non-consensual sexual contact of any type with a resident, as defined at 42 CFR 483.5. Sexual abuse includes, but is not limited to: o Unwanted intimate touching of any kind especially of breasts or perineal area; o All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; o Forced observation of masturbation and/or pornography; and o Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g. posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. Generally, sexual contact is nonconsensual if the resident either: o Appears to want the contact to occur, but lacks the cognitive ability to consent; or o Does not want the contact to occur. The following was reviewed in R90's clinical record, other clinical records and in other facility documents reviewed during the survey: *the use of resident or he refers to R90 unless otherwise specified. 3/2/18 - MDS quarterly assessment of R90 documented a BIMS score of 5 indicating severe cognitive impairment; other behavioral symptoms not directed to others 1 to 3 days a week; limited assistance with locomotion on the unit and supervision with locomotion off the unit with one person physical assist. 3/8/18 3:00 PM - Progress note by E8 (LPN) documented resident noted to be attempting to rub on female patient's legs, specifically resident in room (R18's room #). Resident redirected multiple times and continues to attempt to touch resident (R18) and other female resident. Redirection completed multiple times. 3/9/18 (resolved 6/6/18) - Care planned for tendency to exhibit sexually inappropriate behavior as evidenced by touching others inappropriately with a goal of will have opportunity to engage in appropriate sexual behavior in private areas, as needed. There was no mention of not touching non consenting female residents and there were no approaches to monitor the resident. 3/10/18 4:52 AM - Progress note by E27 (RN) documented monitored by staff thru night, rolling around unit in w/c (wheelchair), observed going in and out of women's rooms/ attempted to uncover blankets on (R359), when questioned by staff, no response given and rolled w/c down hallway. This writer explained to resident that he cannot go into any other room on the unit. continue to monitor. 3/10/18 11:27 AM - Progress note By E8 (LPN) documented resident noted to be in wheelchair rolling around unit. Continues to go into female rooms and take the blankets off them and attempt to touch them inappropriately. Resident was found in room (R358's room #) rubbing patient's thigh and exposed his genitalia to this resident. Patient removed from room, and when questioned there is no response as to why this keeps occurring. Resident noted to enter room (R70's room #) and attempted to rub on thigh multiple times. Removed and redirected. Continued to attempt. Finally able to redirect resident away from room (R70). Resident also noted to attempt rubbing on (R43) thigh while sitting in hallway. Resident stopped and redirected again. This writer was made aware by resident residing in room (R360) that this particular resident (R90) had attempted to rub on their thighs and had exposed genitalia to them. Resident in (R360's room #) yelled at resident to stop and finally left (R360) alone. Continues to enter and attempt to enter multiple female rooms. Resident stopped and redirected. Continues to attempt. Resident reminded multiple times they are not allowed to enter female rooms. 3/10/18 10:37 PM - Progress note by E26 (LPN) documented OOB to w/c. Approach different women x's 3 while sitting @ nurse's station. Resident reminded to keep his hands to himself, without incident. Went to room for dinner @ 5:30 PM and remained in his room rest of shift. Q 15 min checks maintained. There was no evidence that the facility evaluated the effectiveness of the interventions to monitor R90 and stop him from entering other residents rooms. 3/12/18 12:14 PM - Progress note by E8 (LPN) documented Resident noted to be continue (sic) with inappropriate behaviors. Resident noted to be entering multiple female rooms throughout shift. Resident removed and reminded not to enter female rooms. Redirection attempted however resident continues to attempt. Resident noted to rub on females thighs in the hallway. Resident told to stop and educated again however continues with inappropriate behaviors. Resident also noted to attempt to touch this writer, resident told to stop and educated on inappropriateness. When told to stop patient stated 'Why don't you stop telling me what the f@*$ to do? I'll do what I want'. NP initiated new orders for [MEDICATION NAME] 25 mg po daily and (name of mental health provider) consult for medical management. q15-30 minute checks remain. There was no evidence that the facility reviewed and revised interventions to monitor R90 and stop him from entering other residents rooms. 3/12/18 3:48 PM - Facility reported to the State Agency (DHCQ) a resident to resident incident incorrectly classified as other that documented CNA notified the nurse that resident (R358) requested assistance because (R90) came into her room and touched her legs and then exposed his penis to her. CNA removed (R90) from (R358)'s room immediately. Nurse then went in to speak with (R358) to see if she was ok and she was fine. She laughed and said she told him she was not interested and to take his penis back to his room. Resident (R358) did not seem to be negatively affected by the situation. (R90) has never exhibited this behavior before and is being evaluated by the psychologist and tested for UTI due to this unusual behavior. (R358) discharged from facility as she was scheduled with no ill effects. (R90) has not made any attempts at exposing himself. The facility failed to identify this allegation of sexual abuse on 3/10/18 when it occurred resulting in failure to immediately report. The facility documented R90 had never exhibited this behavior before, however the above notes documented R90 was displaying this behavior before he touched R358 inappropriately on 3/10/18. 3/12/18 4:30 PM - Progress note by E9 (SS) documented This writer and CED spoke with (name of resident R90) regarding complaints from staff and other residents of him touching others without consent and exposing himself. He confirmed that this behavior was inappropriate and denied exhibiting any of this behavior. After conversation this writer heard another resident and staff member ask (R90) to not touch her and he was very argumentative w/ (with) staff member telling her to mind her own business. This writer intervened and tried to remind (R90) of our earlier conversation to which he denied/did not remember having and then told this writer to go screw yourself. Referral sent to (name of mental health provider) for psych NP to see as well as visit from psychologist. Facility NP and (managed Medicare) NP both aware of behavior. Will continue to attempt to redirect resident. Behavior has been added to CP (care plan). 3/12/18 6:14 PM - Progress note by E30 (LPN) documented Res(resident) continue (sic) feeling on other res body. Res observed trying to pull out his penis while feeling on female res. Res re-directed x3. Res is now separated from other res. 3/12/18 - Order obtained for (mental health provider) for medical management and antipsychotic medication ([MEDICATION NAME]) for dementia with behavioral disturbance. 3/14/18 4:00 AM - Progress note by E27 (RN) documented resident continues to require monitoring due to behaviors noted this shift. in (sic) w/c attempting in and out of female resident rooms on both units, entered (R5's) room and attempted to remove blankets when staff intervened. noted increased agitation when questioned by staff regarding behaviors. resident has yet to make any attempts into female rooms. note left with (Managed Medicare NP name) requesting to check urine r/o (rule out) infection. 3/14/18 10:53 AM - Progress note by E8 (LPN) documented Resident continues to approach females and enter female rooms. Attempts to pull blankets off and touch thighs. Resident reminded multiple times that it is inappropriate. New order obtained per (doctor name) to send patient to ER for eval(uation). Notified (name) of transfer. Transportation arranged and patient has been picked up by (name of company) ambulance at this time. The facility failed to identify sexual abuse by R90. 3/15/18 - Orders for: [MEDICATION NAME] for mood disorder; [MEDICATION NAME] DR for mood disorder; [MEDICATION NAME] mood disorder; stat head CT (cat scan) to rule out brain lesion. No significant findings were found in the ER workup or the CT scan. The facility failed to revise approaches to the care plan upon return from the hospital. 3/19/18 10:30 PM - Progress note by E26 (LPN) documented Resident maintained in supervised area on unit. Observed attempting to enter female room at end of hall. Re-directed without incident. Then came down hallway and approached another female sitting in hallway. He started to reach across her and was re-directed to his room without incident. 1:1 sitter arrived @ 8 PM. 3/19 - 4/1/18 - per facility time line 1:1 sitter in place, discontinued 4/1/18 due to no behaviors since 3/23/18. 3/22/18 10:25 AM - Progress note by E25 (Director of Recreation) documented .Second report to this writer 3/21/18: During the afternoon movie in AR (activity room), (R90's name) was sitting alone behind the other residents. Sitter asked if staff could supervise him, while she took a break. Recreation (Rec) Assistant was sitting in the room w/residents watching movie and looked down at a document. At that time, (R90's name) moved in between two female residents. Rec (recreation) Assistant heard one of the female residents (R308) he was sitting beside state, don't do that, and if you do that again, I'm going to hit you again. Rec Assistant moved (R90's name) away from female residents and asked female resident what occurred. Upon her return, sitter took (R90's name) from room. Incident reported to this writer upon this writer's return to office. This writer confirmed incident w/female resident who stated that (R90's name) had rubbed up her right inner thigh and was observed by this resident rubbing the thigh of another female resident sitting on his other side. Sitter brought (R90's name) into Resident Council meeting following incident. This writer intervened when this writer observed (R90's name) moving from where he was sitting w/sitter towards another table where two female residents were sitting. This writer wrote up a Concern Form about incident w/female resident in AR and spoke w/3-11 meds nurse about the incidents during the day. Concern forms provided to appropriate Depts (departments). The facility failed to recognize and identify an allegation of sexual abuse and implement effective interventions. 3/23/18 - Order for increased dose of [MEDICATION NAME] DR for mood disorder. March (YEAR) - Review of the Behavior Monitoring and Interventions Sheet revealed that the behaviors removes female resident blankets and enters female rooms was coded too numerous to count' for 17 shifts between 3/13 - 3/31/18. 4/7/18 5:48 AM - Progress note by E27 (RN) documented oob (out of bed) multiple times this shift before 3am, on station one, staff reported resident going in and out of several rooms. brought over to station 2. redirected, resident denied entering any rooms, stating I didn't mean any harm remained in bed after episode. inc (incontinent) care provided by staff. There was no evidence as to what monitoring system was put in place to prevent R90 from going in and out of female resident rooms. 4/7/18 - per facility timeline 1:1 observation by facility staff. 4/10/18 2:50 PM - Progress note by E28 (LPN) documented Resident seen by E24 (psych NP name) today. New orders D/C [MEDICATION NAME] 25mg PO at bedtime. Start [MEDICATION NAME] 25mg PO at 11AM and 8PM. Resident was found on Station I in a female room inappropriately touching her. Daughter-in-law (of R90) made aware of new orders and behavior of resident. The facility failed to recognize and identify sexual abuse. It could not be determined if the approach of having a 1:1 sitter was in place. 4/10/18 - physician's orders [REDACTED]. 4/11/18 3:30 PM - Progress note by E9 documented Notified by staff that rt (resident) was in a female residents room touching her in her groin area. When approached rt denied behavior and became agitated. Sitter service already requested by (Managed Medicare NP). Staff to provide supervision until sitter in place. DON/UM aware. The facility failed to recognize and identify sexual abuse. It was unclear if the approach of having a 1:1 sitter was in place. 4/12/18 - physician's orders [REDACTED]. 4/12/18 - per facility timeline 1:1 sitter reinitiated by managed Medicare contractor for 7 days. 4/13/18 - physician's orders [REDACTED]. 4/17/18 - per facility timeline 1:1 sitter ended and resumed q 15 minute checks by staff. 4/27/18 12:46 PM - Progress note by E8 (LPN) documented Resident noted to be in activities department this morning. When patient noted to feel on female resident from station 1. Activities staff noted to remove patient from area. Patient is now in room. The facility failed to recognize sexual abuse. 4/27/18 revised 6/7/18 - Care planned for problem tendency to exhibit sexually inappropriate suggestions to staff and other residents related to cognitive loss / dementia approaches included: -When sexually inappropriate behaviors occur, approach the resident/patient in a calm, unhurried manner: reassure as necessary -Divert resident by giving alternate objects or activities -Remove resident from environment The care plan lacked approaches to monitor R90 to prevent the abusive behavior. 5/10/18 12:23 AM late entry - Progress note by E6 (RN/UM) documented Since the last evaluation behavior symptoms have decreased. Sexual acts towards other residents/patients none noted Non-pharmacological intervention(s) attempted in the last 30 days:redirection, listen to and attempt to calm, familiarize with surroundings/belongings, remove from environment New meds (medications) have been initiated in the last 30 days with the following target behaviors: continued sexual behaviors . 5/14/18 - Order to increase [MEDICATION NAME] 0.05 mg q week. 5/23/18 - Facility reported incident that occurred at 10:00 AM Resident (R90) was sitting next to resident (R70) both in their w/c's across from the entrance to the activity department. The activity assistant (E29) saw them sitting next to each other as she was exiting the activity department. She immediately wheeled (R90) to the nurses station. She then asked (R70) if (R90) had touched her and she shook her head yes. (E29) then asked where (R90) touched her and she pointed to between her legs. (E29) then went to nurses station and reported what (R70) told her. Both (R90) and (R70) have [DIAGNOSES REDACTED]. 5/23/18 late entry on 5/31/18 1:08 PM - Progress note by E31 (RN/former DON) documented Resident was seen sitting next to another resident outside the activity room entrance. The activity assistant saw (R90) and took him back to the nurses station. Activity assistant then asked the other resident (R70) if (R90) touched her and she shook her head yes. She then asked (R70) where (R90) touched her and she point to between her legs. (R90) was placed on 1:1 sitter at this point and (R70) was assess (sic) for any injuries and when found to have no injuries she then went to activity room for the activity. After talking to facility NP, SS, CNE and CED the decision was made to transfer (R90) to (hospital name) ER for a psych eval. SS contacted (name of) psych facility and was able to get approval to have him admitted to their facility from (hospital) ER. 5/23/18 - Order to transfer to ER for inappropriate behavior. Refer to (name) inpatient psych; Maintain 1:1 observation until transfer to (name). 5/23/18 - Review of facility documentation revealed that on this date a facility wide evaluation of all residents was conducted to determine if R90 had ever sexually abused them. This resulted in the following reports to the State agency DHCQ: - R11 responded that there was a man in a w/c that came in her room and started to rub her left lateral thigh and she yelled at him to get out. She said the nurse (first name) heard her and came in and took him out of her room and down the hall . - R51 responded There was this one time a while ago that a man in a w/c - you know (R90), he came into my room one night while I was sleeping and pulled my leg. When I woke up he left. - R18 responded .she reported that about a month ago she was asleep in her w/c in her room and woke up to (R90) aggressively rubbing her inner thigh enough that it woke her up. She said she yelled at him to stop and get out of her room. She says he stopped and left the room . 5/25/18 7:35 AM - NP note on R32 .Staff states that it was reported to management the (sic) (R90's name) entered a female resident's room and sexually assaulted her. Resident confirmed this (as per staff). The female resident (R32)was sent to ER for further evaluation and (R90's name) for clearance to an inpatient geri (geriatric) psych facility. He was later transferred from (local hospital name) ER to (Psychiatric Hospital name) in Philadelphia 10/11/18 11:18 AM - Interview with R18 revealed (R90) a resident was here, I was sound asleep and he had his fist clear up between my legs going at my privates. R18 stated that it woke her up, she screamed and she reported it. R18 went on to tell the surveyor that R90 is now guarded by staff. 10/18/18 10:15 AM - Interview with E6 (RN/UM) about R90's behaviors revealed that she never saw behaviors. Surveyor reviewed (MONTH) behavior sheet, which showed behaviors that were too numerous to count on several shifts. E6 responded that behaviors would be reviewed quarterly and a note written. When asked about how these sexually abusive behaviors were handled, E6 responded that she was not involved with this and that the social worker and administrator could respond to my inquiry. 10/18/18 10:55 AM - Interview with E1 (CED/NHA) stated that the first incident with R90 happened on 3/9/18 and the resident was discharged . E1 revealed that he was not briefed on any ongoing problems with R90 until 5/23/18 when another incident happened. At that time he reviewed R90's chart and knew the facility had to do something. E1 and E31 (former DON/RN) interviewed all inteviewable residents in the facility to see if they had been affected by R90's actions. Three other residents (R51, R18 and R11) were identified and reported to the state agency. Round the clock 1:1 was started until R90 was sent out to a psychiatric facility. The facility also conducted abuse education with all staff immediately. E1 stated that during the investigation E1 learned that the staff's response towards R90's behavior was related to dementia and there was nothing they could do. 10/18/18 - The facility provided the Abuse Prohibition policy, the evidence that every resident able was interviewed to determine if they were also abused, and evidence that all staff in the building had been retrained in abuse prohibition including sexual abuse. The training was completed on 5/30/18. Surveyor(s) interviewed staff from several departments to determine if they understood how to identify and report sexual abuse with 100% accuracy in answers. The facility repeatedly failed to protect residents from sexual abuse by R90. After the first resident was sexually abused the facility failed to take sufficient action to prevent other residents from being abused. R358, R308, R70, R11, R51, R18, R5, R43, R359, and R360 were known to be touched sexually by R90. It was unclear how many cognitively impaired or discharged residents R90 may have touched inappropriately. This resulted in residents of the facility being in immediate jeopardy for over two months until R90 was moved to a psychiatric facility. This IJ is past non compliance. Once R90 returned to the facility a 1:1 sitter has been maintained 24/7. These findings were reviewed during exit conference on 10/18/18 beginning at 3:45 PM with E1 (NHA) and E2 (DON).

Based on record review, interviews, and review of other documentation as indicated, it was determine that the facility failed to provide the necessary care and services, to prevent the development of avoidable pressure ulcers for one (R3) out of five sampled residents. For R3, who was assessed at risk for PU development, the facility failed to implement pressure reducing and pressure relieving approaches to be consistently followed by staff. On 1/29/17, R3 had a new skin impairment for which the facility failed to review and document the correlating characteristics of the wound, with the physician (per the facility policy) to obtain a wound type diagnosis. This failure resulted in the facility incorrectly identifying the skin impairment as a Moisture Associated Skin Damage (MASD) and not a stage II PU of the sacrum. This resulted in a lack of reassessment of the interventions on the care plan for the risk of development of PU, resulting in the worsening of the stage II PU to an unstageable PU on 2/16/17. In addition, a new avoidable stage II PU was acquired on 3/8/17 and healed on 4/12/17. Findings include: The facility's policy titled Skin Integrity Management, with revision date of 11/28/16 documented the following: Pressure Injury/Ulcer Prevention Guideline: Basic prevention interventions for all patients at risk to include encourage frequent repositioning/weight shifting. For risk factor of impaired/decreased mobility/function, an individualized positioning and repositioning schedule. Skin Integrity Impairment Identified: Notify Dietician for actual wounds. Patient/Family education Wound Characteristics Guide: Indicated to review and document correlating characteristics with physician to obtain wound type diagnosis. Incontinence Associated [MEDICAL CONDITION] (IAD). Definition, a diffuse area (large in shape and wound edges irregular) of rash and/or excoriation due to incontinence. Review of R3's clinical record revealed: 1/19/17 - admitted to the facility with [MEDICAL CONDITION], infection of lungs, diabetes mellitus, and left sided weakness. 1/19/17 - Initial Nursing Assessment documented that R3 had no skin impairment and had a score of 17 on the Braden Scale (mild risk). 1/19/17 - The care plan for risk of skin breakdown as evidenced by incontinence and limited mobility documented the following interventions: - evaluate skin risk factors per protocol. - monitor skin for sign/symptoms of skin breakdown such as redness, cracking, blistering, decrease sensation, and skin that does not blanche easily. - Braden assessment per policy. - Weekly skin assessment by license nurse. 1/24/17 - The care plan for risk of skin breakdown as evidenced by incontinence, limited mobility included two new interventions: -pressure redistribution surfaces to bed per protocol. -pressure redistribution surfaces to chair per protocol. 1/26/17 - Admission MDS assessment indicated that the resident was severly cognitively impaired for decision making, required extensive assistance with bed mobility, transfer, toileting and was incontinent of urine . The resident had no PU and was at risk for developing a PU. Treatments included pressure reducing devices for chair and bed, in addition, R3 was on a turn/repositioning program. The CAA triggered and the facility proceeded with the care plan. Although this documentation indicated that R3 was on a turn and repositioning program, the above care plan for risk of a PU development lacked this intervention. 1/26/17 - Braden scale score of 19 (mild risk for skin breakdown). 1/29/17 and timed 5:48 AM - Progress Note, Change in Condition-Skin, by E5 (RN) documented that R3 had a new skin impairment: a MASD to the gluteal crevice (i.e. gluteal cleft) 2.5 cm. X 1 cm. X and less than 0.1 cm., with no pain. E4 (PA) was notified of the change in condition and order obtained for Z-guard to area every shift for 10 days and evaluate. In addition, R3's responsible party was notified of the new skin impairment. 1/29/17 - Telephone physician's orders [REDACTED]. 1/29/17 - Skin Integrity Report, completed by E5, documented the new skin impairment as a MASD in the gluteal crevice. This form indicated for this type of wound, to check either Incontinence related (IAD) or Not incontinence related, however, these were left blank and not selected. Description of the skin impairment included a length of 2.5 cm., width 1.0 cm., and depth of less than 0.1 cm. with healthy surrounding tissue, healthy wound edges, and appearance was pink. Record review lacked evidence, that the facility reviewed and documented correlating characteristics with physician to obtain wound type diagnosis. 1/31/17 and timed 1:50 AM, by E5, Change in Condition-Skin Follow-up Note documented .T & R in bed. 1/31/17 and timed 5:50 PM, by E14 (RN), Change in Condition-Skin Follow-up Note documented .patient encouraged to turn and reposition. 1/31/17 - MDS assessment indicated that R3 remained relatively unchanged and continued to require extensive assistance with bed mobility, transfer, toileting and was incontinent of urine. R3 had acquired a MASD and remained at risk for developing a PU. Treatments included pressure reducing devices for chair and bed, turn/repositioning program, and application of ointment/medications other than feet. 1/19/17-1/31/17 - Documentation Survey Report (a report generated by the facility, upon surveyor's request, for CNA documentaion of care and services provided to R3) lacked evidence that R3 was turned and repositioned. 2/1/17 and timed 11:54 AM, by E7 (RN), Change in Condition-Skin Follow-up Note documented .T & R in bed. 2/2017 - Physician order [REDACTED]. The initial order date was documented as 1/22/17. 2/2/17 - Braden Scale R3 had a score of 17 (mild risk). 2/1/17 - TPO to cleanse gluteal crevice wound and apply [MEDICATION NAME] and change every 3 days. 2/1/17 - Skin Integrity Report, completed by E7, continued to document that the wound type was MASD with no change in the description of the wound. 2/8/17 - Skin Integrity Report, completed by E7, documented slight improvement in wound measurements as 1.0 cm in length, 0.5 cm in width, and less than 0.1 cm in depth with both surrounding tissue and wound edges as being healthy. 2/8/17 - TPO to discontinue [MEDICATION NAME] to MASD. Apply [MEDICATION NAME] to gluteal crevice MASD q shift. 2/9/17 - Braden Scale R3 had a score of 18 on the Braden Scale (mild risk). 2/14/17 - TPO Duoderm to sacral MASD change every 3 days and PRN. Although treatment to the PU was being reassessed and changed, there was lack of evidence that the facility reassessed interventions to reduce pressure to the affected area. 2/16/17 - Skin Integrity Report, completed by E7, documented that the wound became unstageable PU, since the wound bed was covered with 75% slough with 2.5 cm. in length, 5 cm. in width, and unable to determine the depth. Both the surrounding tissue and wound edges as being healthy. Despite the fact the wound worsened to an unstageable PU, there was lack of evidence that a notification was completed to the Registered Dietician and R3's responsible party. 2/16/17 - TPO Discontinue [MEDICATION NAME] dressing. Cleanse MASD sacral gluteal crevice, pat dry apply Santyl to slough, cover with border gauze daily. 2/19/17 - TPO Stool sample[DIAGNOSES REDACTED] r/t loose stool. 2/20/17 - TPO [MEDICATION NAME] medication for 10 days to treat for positive[DIAGNOSES REDACTED]. 2/23/17 - Nutrition Progress note, by E13 (Registered Dietician) documented acute decline in intake noted to begin on 2/18/17 and continues to be below baseline, decline in oral intake secondary to the [DIAGNOSES REDACTED]icile. The diet was upgraded to dysphagia advanced with chopped meat, extra gravy/sauce on meat. The plan was to monitor and make recommendation as needed. Although E13 had completed a progress note, record review lacked evidence that E13 was notified that R3 had a PU that had worsened. During the survey, surveyor attempted to contact E13, however, was informed that E13 was no longer an employee of the organization. 2/25/17 - Skin Integrity Report, completed by E7, documented that the wound bed had 75% slough, increased in length to 5 cm., increased in width to 5.5. cm., and unable to determine the depth. Both the surrounding tissue and wound edges as being healthy. 2/27/17 - TPO Discontinue Santyl treatment to sacral wound. Apply Silver alginate to buttock, apply skin prep to peri wound, cover with Duoderm to buttock and change q 3 days. 3/2017 POF included: - T & R q 2. Record review lacked evidence that this intervention to relieve pressure was incorporated into the facility's EMR system. 3/1/17 - Skin Integrity Report, completed by E8 (LPN), documented that the PU continued with slough, decreased in length to 3.5 cm., and decreased in width to 5 cm, and unable to determine the depth. Both the surrounding tissue and wound edges as being healthy. 3/1/17 - Nutrition Progress note documented that another Registered Dietician (E14) was asked to review R3 based on weight concerns as well as the MASD that has progressed to stage III breakdown. After discussion with the wound RN, will request additional ProSource three times daily with meals. 3/1/17 TO Pro-Source/scoop three times daily with meals. 3/8/17 - Skin Integrity Report (PU#1 coccyx), completed by E8, documented PU was 100% covered with slough, decreased in length to 2.8 cm., and decreased in width to 4.1 cm, and unable to determine the depth. Both the surrounding tissue and wound edges were healthy. 3/8/17 - Skin Integrity Report (PU #2), completed by E8, documented a new stage II PU of right coccyx area with length measuring 1.8 cm, width of 2.3 cm, and depth of 0.2 cm. The report further documented that this wound was initially identified on 2/16/17. 5/16/17 at approximately 3:00 PM - An interview with E11 (CNA) was conducted. E11 was asked how the CNAs were made aware of care instructions for each residents that they are assigned. E11 verbalized that the care instructions are on the CNA Kardex (communication book for CNAs) in a binder kept at the Nursing Station and in addition, the instructions are in the facility's EMR system and the CNAs document the care given in the computer tablet. E11 proceeded to show the surveyor another resident's record who had completed documented interventions of T & R q 2 hours. 5/17/17 at approximately 11:00 AM, - An interview with E12 (CNA) was conducted. E12 was asked how the CNAs were made aware of care instructions for each resident that they were assigned. E11 verbalized that the care instructions can be obtained from the licensed nurse during verbal shift report, the CNA care plan called the Kardex, and also, the instructions are in the facility's EMR system and the CNAs document the care given in the computer tablet. 5/18/17 at approximately 7:45 AM - An interview with E2 (DON) confirmed at the time of admission, interventions to T & R every 2 hours in bed was not included on the care plan for at risk of skin breakdown. In addition, E2 confirmed this intervention also was not entered into the facility's EMR system, called Point of Care, where the CNAs would document that the interventions were completed. E2 further related that she had observed R3's wound for the first time on 3/8/17 (approximately 38 days since the wound was initially identified), when there was two areas of PUs: one unstageable and one, stage II. In addition, E2 did verbalize that a pressure relieving device for the bed and chair was in place and recalled that a low air loss mattress was applied, however, E2 was not able to provide evidence of this intervention. Additionally, E2 confirmed that the facility does not have evidence of a reassessment of the intervention to relieve pressure when new skin impairment was identified on 1/29/17 or when the wound was observed with slough on 2/16/17. 5/18/17 at approximately 9:04 AM - An interview with E5 was conducted. E5 related that R3 had periods of confusion during the 11:00 PM to 7:00 AM shift and E5 verbalized that the resident was encouraged to turn and reposition and at times, needed staff to assist to turn and reposition. When asked about if E5 could recall any description about the surrounding area around the skin impairment, she indicated that she documented what she saw and does not recall any information at this time. E5 further verbalized since she had identified the skin impairment as MASD, there was not a need to reassess the intervention to prevent PU. E5 was asked, where would the CNAs document the the care provided to R3; E5 verbalized that it would be documented in the facility's EMR. 5/18/17 at approximately 11 AM - An interview with E6 (RN UM for Transitional Care Unit) revealed that as an UM, she reviewed the care plan for new residents. When asked about the interventions that were added on 1/24/17, which included the pressure distribution surfaces to bed and chair, E6 related that it was most likely not on the care plan, thus, she added these interventions. E6 verbalized that the pressure redistribution surfaces on the bed were standard for all the beds in the facility. E6 recalled observing R3's PU and at that time, the wound had slough. E6 verbalized although the order to T & R q 2 h was on the February physician's orders [REDACTED]. 5/18/17 at approximately 3:00 PM - An interview with E9 (CNA) revealed that it was her practice, to turn and reposition residents every two hours for those residents who may not be able to do so themselves. E9 recalled R3 needing staff's assistance to T & R every 2 hours and would document this in the facility's EMR system. E9 was informed by the surveyor that the intervention to T & R every 2 hours was not in the facility's EMR system and E9 related although may not have been in the system, she had assisted R3 to T & R every 2 hours since she recalled that R3 had a small area on top of the tailbone and was aware of the importance of the T & R schedule. In addition, E9 verbalized that she reported this to E7 (RN). 5/18/17 at approximately 1:00 PM - An interview with E8 (LPN), the facility's wound care nurse was conducted. E8 verbalized that wound rounds are typically completed weekly with E4(PA), however, at times, due to staffing limitations, weekly wound rounds may or may not be completed. E8 related that she assessed the wound on 2/1/17, as documented on the Skin Integrity Report and recalled that the size of the wound was size of a pea. It was E8's assessment that although the area was size of a pea, the wound type was MASD and not PU. 5/18/17 at approximately 3:15 PM - An interview with E10 (RN), the admitting RN on 1/19/17 confirmed the T & R intervention was not incorporated into the at risk care plan for skin breakdown, created and initiated on 1/19/17. In addition, this intervention was not manually entered into the facility's EMR system for CNA documentation. 5/18/17 at approximately 3:45 PM - An interview with E4 (PA) revealed that she assessed the wound for the first time on 2/17/17 and it was a sacral unstageable PU. E4 verbalized during the weekly rounds, with the facility's wound care nurse, interventions are reassessed. During this conversation, the surveyor informed E4 that the facility failed to have evidence that T & R was consistently performed. In addition, the surveyor showed the Skin Integrity Report dated 1/29/17 and presented the inconsistencies between the description on this documentation and the wound characteristics defined in the facility's policy. E4 concurred the presence of the inconsistencies. Surveyor verbalized that based on the description of the wound on 1/29/17, it was most likely a stage II PU. 5/23/17 at approximately 9:30 AM, a telephone interview was conducted with E7(RN). E7 verbalized that she had recalled E9 advising her of a new skin impairment, most likely the morning of 1/29/17. E7 further verbalized that the area of the skin impairment was not diffused and was contained. E7 related that beginning with the 2/16/17 weekly assessment, since the resident had diarrhea and slough was present, it was iffy at that point if it was a MASD and subsequently, E2 and the facility's wound care nurse identified this as an unstageable PU. E7 related that it was the standard of care to T & R q 2 hours in her unit and the CNAs are made aware during report as well as in the task section of the facility's EMR system. Facility's failures included: -Implementation of preventative measures and interventions for the development of a pressure ulcer, including an individualized positioning and repositioning schedule on and after admission on 1/19/17. - Accurate identification of the type of wound, when R3 had a new skin impairment on 1/29/17. The incorrectly identified the type of wound as MASD and not a stage II PU. -The failure to accurately identify the type of wound, resulted in the lack of reassessment of the interventions to relieve pressure from the affected area which resulted in the PU worsening to unstageable on 2/16/17. Despite the fact the facility identified the unstageable PU, the facility failed to implement a new care plan for this actual PU and failed to reassess the interventions on the at risk for skin breakdown care plan. -On 3/8/17, a new stage II PU #2 was identified on the right coccyx area measuring 1.8 cm in length, 2.3 cm. in width and 0.2 cm in depth. Findings reviewed on 5/18/17 at approximately 5:15 PM with NHA (E1) and E2.

Cross refer F309 example #1a, F 517 Based on record review, interviews, review of facility and other documentation as indicated, it was determined that for one (R91) out of 37 Stage 2 sampled residents, the facility failed to ensure the resident was transferred using the correct assistive device. On 7/7/15, R91 was involved in a facility-wide evacuation due to a fire and sustained two broken bones in her left ankle when staff failed to use the correct assistive devices to transfer R91, on two occasions. The facility also failed to ensure the environment was free from accident hazards in five rooms (101,120, 123, 126, and 203) out of 32 reviewed. Findings include: 1. The facility's policy entitled Physician/Mid-level Provider (PA, NP) Notification, dated 1/1/14, stated that if unable to contact the attending physician/mid-level provider the medical director will be contacted. According to the manufacturer's warning in the user manual for the sit-to-stand lift used in the facility, a person (resident) must be able to support the majority of their own weight, otherwise injury may occur. Review of facility documents revealed the following: R91 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. 5/25/12 - R91 was care planned for the following: - Chooses to remain in bed and does not want to get out of bed or out of room; and - At risk for falls due to impaired mobility with an approach that included assisting R91 in and out of bed with 2 person assist using a mechanical lift. 4/15/15 - The facility's Lift-Transfer-Repositioning evaluation stated that R91 required a total lift (hoyer) for transfers in and out of the bed. 5/24/15 - Annual MDS Assessment indicated the resident was totally dependent on staff for locomotion (not able to walk) and had no memory problems. 7/2015 - R91's July weight was 301 pounds. 7/7/15 - R91 was involved in a facility-wide evacuation due to a fire. Review of facility documents and interviews revealed that during the evacuation, two incorrect transfers (manual lift and sit-to-stand lift) occurred and R91 sustained two broken bones in her ankle. 7/7/15 timed 9:47 PM - A nurse's note by E12 (LPN) stated R91 complained of left foot and ankle pain. No swelling or discoloration noted with limited range of motion. Undated - A facility written statement by E15 (RN) stated that on 7/7/15 around 9:30 PM, the RN was told by E12 (LPN, medication nurse) that R91 complained of pain, swelling and decreased range of motion in her left foot. After the medication nurse faxed the physician with an x-ray request, the RN went to the resident's room and lifted the blanket to assess R91's foot/ankle. Resident was sleeping and there was no obvious swelling or discoloration of her left foot/ankle at that time. The facility failed to contact the physician with R91's change of condition. Instead, the facility faxed an x-ray request after office hours to the physician's office. 7/8/15 at 4:31 PM - A nurse's note stated R91's left foot/ankle x-ray was called to (name of x-ray company) after receiving an order from E16 (physician). This occurred approximately 16 hours after an x-ray request was faxed to the physician's office when the office was closed. The facility failed to contact the medical director when the attending physician did not respond for over 16 hours to a faxed x-ray request. 7/8/15 at 6:46 PM - A nurse's note stated R91's x-ray revealed displaced fractures of the distal tibia and fibula with joint alignment maintained and soft tissue swelling. Results were called to E16 (physician) and E2 (DON). The x-ray results were discussed with R91 and she agreed with the physician's plan to contact an orthopedic surgeon the next day. 7/8/15 at 6:48 PM - A change in condition nurse's note stated there was slight left ankle swelling, a large bruise on the inner side of the ankle and R91 complained of decreased mobility of her ankle. During this 19 hour time frame, there was no reassessment recorded by nursing or medical staff. The facility failed to reassess R91's ankle in a timely manner. Reassessment was not completed or documented for approximately 19 hours after the initial assessment. 7/9/15 at 10:36 AM - A nurse's note stated the bruise remained on R91's left ankle and R91 had an appointment scheduled with the bone doctor at 2 PM later that same day. 7/9/15 at 10:42 AM - A nurse's note summarizing R91's evacuation on 7/7/15 stated she was part of a full-facility evacuation related to a fire in the facility. When approached, R91 refused to be taken out. After all residents were evacuated, staff returned to R91 and instructed her that it was not a drill and that she had to leave her bed and the facility for her own safety. Five staff members assisted (manual lift) her to a wheelchair. All the while R91 was resisting and fighting the staff. R91 did not fall nor was staff aware of any injury to the resident. One staff member held her legs during transfer to the wheelchair and out of the facility. Once outside, her legs were propped up on a chair with a pillow. When able to come back into the building, staff continued to support R91's legs and she was assisted back to bed using a mechanical (sit-to-stand) lift. Staff reported that R91 remained agitated and was kicking at them as they used the sit to stand lift. The facility failed to use the correct lift device to transfer R91 out of bed according to her plan of care. 7/9/15 at 12:48 PM - The incident report filed with the Division of Long Term Care Residents Protection, two days after the the incident of 7/7/15, stated that R91 reported a lot of ankle pain to the nurse. R91 had a history of [REDACTED]. Information was relayed to the attending physician who ordered the x-ray (not done until the next day-7/8/15). X-ray showed 2 broken bones in R91's left ankle. 7/9/15 at 6:36 PM - A nurse's note stated that R91 returned from seeing the bone doctor at 4:30 PM wearing an ankle splint. The facility's investigation revealed the following written statements from staff involved during and following the events on 7/7/15 with R91: - E7 (CNA) statement dated 7/9/15 stated when R91 was approached to get out of bed she was not ready so the resident was left to be the last resident to evacuate. After getting the resident to the chair, her feet were held up and set on a chair once outside. At no point sis (sic) the resident state she was in any pain. When staff tried to put R91 back to bed by manually lifting her they could not do so. E10 (RN) was called to help and it was that nurse who recommended the sit-to-stand lift. Before the transfer back to bed R91 was anxious and fought staff and pushed herself backwards and kicked the machine away with her feet. - E9 (CNA) statement dated 7/9/15 stated that R91 told staff she could not stand and her feet could not touch anything or they would hurt. The resident was manually lifted out of her bed and put in a wheelchair while staff held her legs up. Since she was wheeled out with one CNA holding her legs up, her feet never touched the floor or ground. Once outside, R91's feet were placed on a chair. Staff had a hard time figuring out how to get the resident back in bed. The resident was anxious and was crying and screaming that staff were hurting her before anyone had touched her. R91 was flailing her arms and legs, kicking at the (sit-to-stand) lift and pushing the lift back. The resident continued to kick and scream while staff got the (sit-to-stand) lift belt around her. The nurse used the buttons to control the lift and helped raise R91 from the front. Two CNAs were on either side of her to help lift her arms and legs and two other CNAs were behind her pushing to help get her out of the wheelchair. R91 was put in the bed and throughout the rest of the shift did not mention to E9 that she had pain. - E8 (CNA) statement dated 7/14/15 stated that the resident was very resistant saying she could not stand when approached for evacuation. Two CNA's had the resident's arms, one on each side. Another CNA had her feet while E11 (RN) was in back of the resident. R91's feet never touched the floor and were held up by a CNA until wheeled outside when they were set on a chair with a pillow. After the fire numerous staff attempted to lift R91 back to bed but she was wedged tight in the wheelchair, the mechanical lift was obtained. The resident was kicking at the lift and pushing it away with her feet. E10 was summoned to assist and the nurse instructed staff to use the sit-to-stand lift. The nurse and a CNA put R91 on the lift then she was lifted just off the chair and three CNAs held the top of her pad to guide her to the bed. She never yelled out about instant pain nor complained of pain once in bed. - E12's statement dated 7/14/15 stated when administering medications before supper on 7/7/15, R91 complained of ankle pain and was unable to move her left foot. No swelling or discoloration was noted when compared to her right ankle. Charge nurse was notified of the pain and request for x-ray was faxed to the attending physician. - E14 (CNA) in an undated statement stated the resident yelled and screamed I can't get up. My feet can't touch the floor. Six people lifted her to a wheelchair and evacuated her out of the building. 9/4/15 at 10:35 AM - In an interview, E8 (CNA) acknowledged that a split leg sling (type of sling used by R91 with the hoyer lift) could go under someone who was already up in a chair. 9/10/15 at 9:38 AM - In an interview, E10 (RN) stated he was only present for returning R91 back to bed. The nurse stated that the resident was sliding out of the chair so they used the sit-to-stand device. When asked to describe how the sit to stand lift was used for R91's transfer back to bed, E10 said they put the belt around the resident and attached the belt to the lift. The machine was raised so the resident stood up a little while, a CNA helped with each of R91's arms and other CNAs pushed the resident up from the back. E10 confirmed the resident did put weight on her feet. When asked if the wheelchair had removable arms, E10 said he was not sure. When asked if a resident could be evacuated in a bed, E10 stated a bed could be taken out the front door. 9/10/15 at approx. 3:25 PM - E2 (DON) confirmed there should have been documentation of a nursing assessment. E2 stated there was missing documentation and you can't prove it if it's not documented. DON stated that E10 was the charge nurse that Wednesday morning and I know in my heart of hearts it (assessment) was done. For R91, the facility failed to use the correct device when transferring R91 in and out of bed, which resulted in two broken bones in her left ankle. Findings were reviewed with E1 (NHA) and E2 on 9/10/15 at 3:00 PM. 2. During the environmental tour with E6 (FMD) on 9/3/15 between 9:30 AM and 11:00 AM, the following hazards were observed. Room 101: -Exposed toilet bolts were rusty. Room 120: -Exposed toilet bolts were rusty. Room 123: -Exposed toilet bolts were rusty. Room 126: -Observed linoleum floor in the bathroom was wavy creating a tripping hazard next to the door by the adjoining room. -Exposed toilet bolts were rusty. Room 203: -Exposed toilet bolts were rusty. All findings were confirmed with E6 during the environmental tour on 9/3/15 at approximately 11:00 AM.

Based on record review, interviews, and review of facility's policy and procedures, it was determined that the facility failed to ensure that one (R143) out of 51 sampled residents who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. R143 was assessed at risk for development of a pressure ulcer (PU) and on 4/8/12, R143 had a new PU of the left posterior ankle (achilles) secondary to the pressure from the knee immobilizer. The facility failed to consult the orthopaedic surgeon (who ordered the immobilizer), failed to reassess and implement interventions to relieve pressure to the area. These multiple system failures resulted in the PU worsening to an unstageable necrotic PU requiring debridement by a podiatrist. Findings include: 1. R143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented that R143 required extensive assistance of two plus staff persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and did not ambulate. In addition, R143 was at risk for developing a pressure ulcer (PU) , but did not have a PU on the left lower extremity at the time of the assessment. CAA (Care Area Assessment) triggered for PU and a care plan was initiated. Review of the admission nursing assessment dated [DATE] documented that R143 had mild [MEDICAL CONDITION] of LUE (left upper extremity) and LLE (left lower extremity) and did not have any skin impairment of bilateral foot, heels, and ankles. The facility's policy and procedure titled "Skin Integrity Care Delivery Process" indicated that all residents will be assessed for potential loss of skin integrity by using the Braden Scale for predicting PU on admission/re-admission, quarterly, and with any significant change in condition. In addition, this document contained guideline titled "Pressure Ulcer Prevention Guideline" which included " Basic Prevention Interventions for all patients at risk" stated: - Perform daily observation of the skin. - Provide padding for casts, braces, and splints. - Avoid/limit skin to skin contact, friction, or shearing forces. May use pillows, heels, elbow protectors to keep bony prominences from rubbing. R143 was assessed as "mild risk" on admission (3/29/12) and on 4/7/12 utilizing the Braden Scale. The admission physician's orders [REDACTED]. - "Skin checks weekly. Brace to LUE at all times, immobilizer to LLE at all times. Remove for hygiene-do not bend knee. Cleanse incision to LUE and LLE with [MEDICATION NAME] daily. Do not remove. NWB (No weight bearing) LLE. Skin prep. to right popliteal blister BID (twice daily)." The care plan titled "Resident is at risk for skin breakdown as evidenced by immobility developed and initiated on 3/31/12 included a goal that R143 will not show signs of skin breakdown for 30 days. Interventions included: - Assist resident in repositioning q (every) 2 hrs (hours). - Encourage resident to consume all fluids during meals. - Evaluate for any localized skin problems, i.e. dryness, redness, pustules, inflammation. - Evaluate for skin risk factors per protocol. - Monitor skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily. - Norton/Braden assessments per policy. - Pressure redistribution surfaces to bed and chair per protocol. - Weekly skin assessment by licensed nurse. Review of the Treatment Administration Record (TAR) for April 2012 revealed that the weekly skin checks scheduled for 4/5/12 were blank, thus, lacking evidence that the skin check was completed. In addition, review of the nurses notes (N.N.) for 4/5/12 lacked evidence that the skin check was completed per the above care plan. Interview with E2 (Director of Nursing) on 6/5/12 at 10:30 AM confirmed that the facility failed to complete the weekly skin assessment on 4/5/12. Further review of the April 2012 TAR documented a new intervention to "Monitor skin above left heel daily." An interview with E20 (nurse) who initiated this intervention on 6/5/12 at approximately 3 PM revealed that the area above the left ankle became red in color due to the immobilizer hitting and rubbing the area above the heel. E20 further verbalized that she applied skin prep. and pad to the affected area. Per the facility's above policy, when a skin integrity impairment is identified the following processes are to be initiated: -report on the 24 hour summary report. -complete a " Skin Integrity Report ." -interdisciplinary care plan (ICP) to include approaches to stabilize or improve co-morbidities and interventions limiting the effects of risk factors associated with PU. -notify dietician for actual wounds. -notify therapy department of actual wounds (e.g. pressure ulcer, venous ulcers, arterial ulcers, or diabetic ulcers which may respond to intervention) or -risk factors including impaired mobility, seating and positioning deficits, or swallowing deficits. Although R143 had a new skin impairment of the left achilles on 4/8/12, record review lacked evidence of a "24 hours summary report", "Skin Integrity Report, ICP, notification of dietician, notification of therapy department. Record review and staff interviews lacked evidence that the facility implemented interventions to relieve pressure from R143's left achilles PU. On 4/9/12, a "Skin Integrity Report" was initiated which documented a new skin impairment of the left heel. Type of wound was noted as pressure and under other wound type, "DTI" or deep tissue injury. Stage of the PU was documented as "unst." or "unstageable." Appearance of the PU was documented as "necr." or necrotic with dimensions of 4.5 cm. (centimeter) length (L), by 6 cm. width (W), and depth (D) as "unk" or unknown. On 6/4/12 at 11 AM, an interview with E21, the nurse who initiated the above "Skin Integrity Report" on 4/9/12 revealed that the above area was discolored and skin hard to touch and not supple. The physician was notified and family, however, there was no evidence of this in the record. E21 indicated that when she did the daily treatment to the left knee surgical site prior to 4/9/12, E21 did not do the entire leg. Despite the fact that R143's left achilles PU worsened with necrosis with the above dimensions on 4/9/12, record review again lacked evidence of a "24 hour summary report", "Skin Integrity Report, ICP, notification of dietician, notification of therapy department. In addition, the facility failed to reassess the interventions, implement a care plan for the new PU, and failed to implement interventions to relieve pressure caused by the immobilizer. An interview with E24 (Registered Dietician) on 6/11/12 at approximately 11 AM confirmed that E24 was not contacted regarding the new PU, however, E24 became aware of the PU during routine dietician review. An interview with E25 (Director of Therapy Services) on 6/11/12 at approximately 12:27 PM revealed that the Therapy Department was notified during a weekly Utilization Review meeting on 4/11/12 that R143 was being treated for [REDACTED]. An interview with E13 (Certified Nursing Assistant) on 6/7/12 at approximately 8:20 AM revealed that she recalled that there was a blister in the area of the left ankle due to immobilizer rubbing in the area. E13 indicated that when R143 was given a bath, E13 removed the immobilizer and the resident was not combative. E13 further verbalized that when R143 was in bed, the immobilizer moved and would move down lower to the leg, thus, E13 needed to pull the immobilizer up the leg to ensure proper placement. In addition, E13 reported that a shorter length immobilizer was obtained which was currently being utilized. Review of the physician's orders [REDACTED]. to DTI, left posterior ankle q. shift X 14 days then re-evaluate. Remove left knee immobilizer and LUE immobilizer q shift to monitor skin integrity." Subsequent assessments on the "Skin Integrity Report" were completed by E2 which documented the continued appearance of necrosis with no depth from 4/12/12 through 5/3/12. An interview with E2 on 5/29/12 at approximately 8:28 AM reveled on 4/9/12, the left posterior ankle PU was first identified as unstageable DTI with appearance discolored-darker than other parts of her body/different consistency than other skin,intact, and softness. The PU was secondary to the leg immobilizer. On 4/16/12, R143 had a follow-up appointment with the orthopaedic surgeon. Subsequent to this appointment, physician's orders [REDACTED]. Left knee, keep in immobilizer. Do not bend." Although R143 had acquired a new PU secondary to the immobilizer, record review lacked evidence that the orthopaedic surgeon was informed and consulted. An interview with staff at the orthopaedic surgeon's office on 6/5/12 at approximately 4:30 PM revealed that during the follow-up visit on 4/16/12, they were not informed of the PU of the left achilles. physician's orders [REDACTED]. to left posterior ankle, clean left posterior ankle with wound cleanser, pat dry, apply sure prep. to surrounding wound edges, apply Hydrogel to wound bed, cover with gauze and secure. Change dressing daily and PRN (as needed)." Subsequent assessments on the "Skin Integrity Report" were completed by E2 which documented the continued appearance of necrosis with no depth from 4/12/12 through 5/3/12. Beginning on 5/10/12, the PU had depth of 0.2 cm. and on 5/17/12, the tendon was exposed. On 5/14/12, a consultation with a podiatrist was ordered for possible debridement of left ankle. Review of the "Report of Consultation" dated 5/24/12 documented that the podiatrist debrided the necrotic tissue from the left achilles with new wound care orders for Hydrogel daily was implemented. Subsequent "Report of Consultation" dated 6/4/12 by the podiatrist included recommendation to "continue wound care with Hydrogel and to continue to offload and avoid pressure from knee brace." Subsequent interview with E21 on 6/7/12 at approximately 9:10 AM revealed that the knee immobilizer that R143 was initially admitted with was too long and had to be pulled up to R143's thigh area because the immobilizer kept sliding down R143's leg. E21 verbalized that a piece of yellow foam was obtained from therapy which was placed in the immobilizer to minimize the friction to the left achilles area. E21 did not recall whether the skin impairment was present in the left achilles prior to obtaining the foam. Lastly, E21 verbalized that she does not recall a blister or a reddened area prior to 4/9/12 and that the first time she observed the skin impairment was on 4/9/12. A meeting with E1 (Administrator), E2 (DON), E22 (Manager of Clinical Operations), and E23 (Senior Clinical Education Specialist) on 6/7/12 at approximately 11:45 AM revealed that they interviewed E13 who verbalized that R143 had a blister in the left achilles area. In addition, E13 verbalized that the previous knee immobilizer was in the laundry department. This immobilizer was obtained and E23 verbalized that it was likely that this immobilizer was causing the pressure on the left achilles area. In addition, E23 verbalized that if there was a blister, it could have been a stage II PU or suspected DTI. E23 related that whether this was a stage II PU or suspected DTI, pressure relief would have been indicated. Above findings were reviewed with E1 (Administrator), E2 (Director of Nursing), and E22 (Manager of Clinical Operations) on 6/7/12 at approximately 2 PM. On 6/7/12 at approximately 3 PM, the surveyor was given a written statement by E2 which documented E2's recollection of the PU observed on 4/12/12 : wound was located on the posterior ankle at the achilles on the left foot. The wound presented as intact, discolored, firm skin with a spongy/boggy feel to the center of the wound under the firm skin." A subsequent interview with a staff member at the orthopedic office on 6/7/12 at approximately 3:48 PM revealed that if the treating physician was informed of the pressure caused by the immobilizer and consulted, adjustments to the immobilizer could have been completed.

Based on record review, interviews, and review of facility's policy and procedures, it was determined that the facility failed to ensure that one (R4) out of 12 sampled residents who was admitted to the facility with pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. R4 was admitted to the facility with a left heel suspected deep tissue injury (a pressure sore) and the facility failed to ensure that the dietician was notified and consulted. In addition, the facility failed to ensure an intervention to float heels was completed. Findings include: 1a. R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated [DATE] documented a presence of a left heel suspected deep tissue injury (SDTI). In addition, R4 required extensive assistance of two plus staff persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and did not ambulate. The facility's policy and procedure titled "Skin Integrity Care Delivery Process" indicated that when a skin integrity impairment is identified, the Registered Dietician was to be notified of the actual wound. Although R4 was admitted with a skin impairment on 8/2/12, record review lacked evidence of a notification of dietician. An interview with E9 (Registered Dietician/RD) on 8/8/12 at approximately 2 PM revealed that E9 was on vacation when R4 was admitted to the facility, however, in her absence, another RD would have been available if a notification was received regarding a new resident with a pressure sore. E9 confirmed the lack of notification when R4 was admitted on [DATE]. E9 verbalized that R4 was scheduled for a routine new resident nutritional assessment, thus, this assessment was currently being conducted on 8/8/12, 6 days after admission. Subsequent to the above interview with E9, a care plan titled "potential nutritional risk d/t (due to) wound, therapeutic diet, low [MEDICATION NAME]." was created and initiated on 8/8/12 with a goal that R4 will consume 75% of at least two meals per day for 90 days." Interventions included: - MVI (multiple vitamin) daily. - Weigh per policy and alert dietician and physician to any significant loss or gain. - Monitor changes to nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated (sic). - Offer high protein HS (bedtime) snacks." A follow-up interview with E9 on 8/9/12 at approximately 1 PM revealed that upon completion of the nutritional assessment, a physician order [REDACTED]. 1b. Review of R4's care plans titled "Resident is at risk for skin breakdown as evidenced by limited mobility" developed and initiated on 8/2/12 and a care plan titled "Actual skin breakdown related to limited mobility" developed and initiated on 8/2/12 included an intervention to "Float heels while in bed." An observation of R4's left heel SDTI was conducted with the presence of E6 (nurse) on 8/8/12 at approximately 11:45 AM. R4 was observed lying in bed. The surveyor was informed that a heel lift device was utilized when R4 was in bed by E6. The surveyor was provided two, heel lift devices. At the conclusion of this observation, the surveyor requested evidence from the facility that this device provided floating of the heel as care planned. On 8/9/12 at approximately 11 AM, during an interview with E2 (Director of Nursing) confirmed that the above device did not float the heels but rather reduced pressure to the heels.