Every finding on record at Crescent Care of Elgin

Based on interview and record review, the facility failed to provide the required twelve (12) hours per year of continuing competence training for Certified Nursing Assistant (CNAs), including dementia management training. This failure has the potential to affect all 68 residents, as indicated in the facility's Centers for Medicare and Medicaid Services (CMS) Form 671, Long-Term Care Facility Application for Medicare and Medicaid report of their current census. The findings include:On 12/2/2025 at 10:20 AM, review of the facility's Certified Nursing Assistant (CNA) orientation packet showed no evidence of dementia-related in-services. V16 (Human Resources Coordinator) stated dementia training hours are not something she tracks, nor was she told that dementia training was required for CNAs to work on the floor. A sample review of three CNA personnel files also showed no documentation of dementia training. On 12/3/2025 at 11:54 AM, V19, V20, and V21 (CNAs) stated they do not keep track of their annual training hours. When asked about specific training topics completed in the past year, they did not report receiving dementia training. Review of the facility's 12/3/2025 Diagnosis Report identified 31 current residents with diagnoses of dementia and/or Alzheimer's disease. On 12/3/2025 at 9:40 AM, V1 (Administrator) and V2 (Director of Nursing) stated the facility does not have a specific policy regarding staff education requirements, including dementia training. V1 and V2 reported the facility provides 6 hours of general staff training upon hire and 3 hours of annual training thereafter. They also stated they are not required to provide a specific number of dementia training hours because the facility does not include a memory care unit.

Based on observation, interview, and record review, the facility failed to label residents' medications when opened. This applies to 4 out of 4 (R79, R65, R63, and R17) residents reviewed for medication storage in a sample of 22.The findings include:1. On 12/03/2025 at 8:20 AM, the facility's first-floor medication cart #2 was checked with V5 (Registered Nurse/RN). R79's Symbicort aerosol inhalers were opened and not labeled with open or discard dates.R79's Order Summary Report dated 12/03/2025 showed an active order for Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 2 puff inhale orally two times a day.2. On 12/03/2025 at 8:20 AM, the facility's first-floor medication cart #2 also had R65's Fluticasone aerosol inhaler was opened and not labeled with an open or discard date. V5 said she was unsure why the opened inhalers were not labeled. R65's Order Summary Report dated 12/03/2025 showed an active order for Fluticasone-Umeclidinium-Vilanterol 1 inhalation inhale orally one time a day.3. On 12/03/2025 9:30 AM, the facility's second-floor medication cart #1 was checked with V6 (RN). R63's Symbicort, Atrovent, and Levalbuterol aerosol inhalers were opened and not labeled with open or discard dates.R63's Order Summary Report dated 12/03/2025 showed active orders for Symbicort Aerosol 160-4.5 MCG/ACT 2 puff inhale orally two times a day, Levalbuterol Tartrate 1 puff inhale orally every 6 hours as needed, and Ipratropium Bromide HFA Aerosol Solution 17 MCG/ACT 1 puff inhale orally four times a day.4. On 12/03/2025 at 9:30 AM, the facility's second-floor medication cart #1 also had R17's Albuterol inhaler was opened and not labeled with an open or discard date. V6 said all opened inhalers should be labeled with open dates to ensure they are stored and discarded properly. The facility's policy titled Medication Labeling and Storage undated, said the facility labeled medications and biologicals in a manner consistent with currently accepted pharmaceutical practices, federal, and state requirements. The policy continued to say that the nursing staff was responsible for maintaining medication storage, including in a safe manner.

Based on observation, interview, and record review, the facility failed to obtain orders from the physician to have resident medication at the bedside. The facility also failed to complete self-administration of medication assessments. This applies to 3 of 3 residents (R1, R63, and R70) reviewed for medications in a sample of 22.The findings include: 1. On 12/01/2025 at 10:11 AM, the following medications were on R63's bedside table: Fluticasone Propionate Nasal Spray, Hydrocortisone ointment 1%, Atrovent (Ipratropium Bromide) inhaler, Spiriva Respimat inhaler (Tiotropium Bromide), Levalbuterol Tartrate (Xopenex inhaler). R63 stated that the medications are always kept in her room. She stated she has emphysema and chronic bronchitis. R63 said, No one told me how to do these inhalers or cream. I've been using these for years and I know how to do it. It's always kept here. Review of R63's POS (Physician Order Sheet) shows orders for the following medications: Fluticasone Propionate Nasal Suspension 1 spray in both nostrils two times a day for allergies, Hydrocortisone External Ointment 1%--apply to affected topically every 24 hours as needed, Ipratropium Bromide HFA Aerosol Solution 17 MCG/ ACT—1 puff inhale orally four times a day related to COPD with acute exacerbation, Spiriva Respimat inhalation aerosol solution 1.25 MCG/ ACT (Tiotropium Bromide)—2 puffs inhale orally one time a day related to COPD, Xopenex HFA inhalation aerosol 45 MCG/ACT (Levalbuterol Tartrate)—1 puff inhale orally every 6 hour as needed for SOB (Shortness of Breath). There were no orders for the medications to be kept at the bedside. Review of R63's electronic medical record shows there is no self-administration of medication assessment form uploaded. R63 did not have a care plan regarding self-administration of medication. 2. On 12/1/25 at 11:31 AM, R1 had Carboxymethylcellulose Sodium Ophthalmic Solution 0.5% on his bedside table and (brand name) Premium Saline spray on his dresser. R1 said the medications are always kept in his room. He said the nurse didn't teach him how to use it. He's been using it for a very long time. Review of R1's POS shows orders for Carboxymethylcellulose Sodium Ophthalmic Solution 0.55—Instill 1 drop in both eyes four times a day for dry eyes related to age-related nuclear cataract unspecified eye. There was no order for the nasal spray. There were no orders for the medications to be at the bedside. Review of R1's electronic medical record shows there is no self-administration of medication assessment form uploaded. R1 did not have a care plan regarding self-administration of medication. On 12/02/2025 10:02 AM, V2 (Director of Nursing) stated that medications brought from home should be locked up and the nurse should call the family and the doctor for it to be at the bedside. Then, the nurse should do an assessment to see if the resident can self-administer medication without any problems. 3. On 12/1/25 at 11:14 AM, R70 had three Lidocaine patches, one bottle of (brand name) Premium Saline Spray, two vials of nebulization solution, and one bottle of (brand name) Tears lubricant eye drops on his nightstand. R70 said he keeps them in his room for easier access. R70 said he knows how to use them and doesn't need anyone to teach him or to remove the medication from his room. Review of R70's POS shows orders for Lidocaine External Patch 45 – Apply to lower back topically once daily; Artificial Tears Ophthalmic Solution 0.2-0.2-1% (Glycerin-Hypromellose-Polyethylene Glycol 400) – Instill 1 drop in both eyes four times a day for dry eyes; Saline Nasal Spray Nasal Solution 0.65% - 1 spray into both nostrils every 2 hours as needed; and Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% – Inhale 2.5 MG orally via nebulizer daily and as needed. Review of R70's electronic medical record shows there is no self-administration of medication assessment form uploaded. R70 did not have a care plan regarding self-administration of medication. Facility's policy titled Self-Administration of Medications Management (6/29/17) shows the following: Procedure: 1. When determining if self-administration is clinically appropriate for a resident, a licensed nurse will complete the Evaluation for Resident Self-Administration of Medications to aid in the determination of resident's ability to self-administer medication. In addition, if resident's medications include respiratory inhalants, the self-administration evaluation of respiratory inhalants will be completed.3. Determination of the resident's ability to self-administer medication by the IDT (Interdisciplinary Team) will be documented in the resident's medical record and on the care plan. 5. A periodic evaluation of the resident's ability to self-administer medication will be performed by the IDT.6. A physician's order will be obtained and recorded in the chart. The order also will include which specific medications can be kept at the bedside.

Based on interview and record review, the facility failed to give residents and/or their POA (Power of Attorney) written notification for the reason of the transfer to the hospital. The facility also failed to provide a bed hold notice and notify the ombudsman. This applies to 2 of 4 residents (R5, R63) reviewed for transfers and discharges in a sample of 17. The findings include:1. R5's face sheet shows an original admission date of 12/4/25. R5's progress note dated 10/15/25 at 3:36 PM shows the following: (R5)'s BP (Blood Pressure) noted to be 73/39, Temperature 97.7, Pulse 109. Vital signs rechecked and BP 79/32, Pulse 66, Temperature 99.0, Respiration 18, and Oxygen Saturation 95% on room air. NP (Nurse Practitioner) in the building with new order to send (R5) to ER (Emergency Room) via 911 for further evaluation. Son and Daughter notified. 911 called. Approximately 3:30 PM, (R5) was transported to the hospital via 911. Report called to ER nurse.Review of R5's electronic medical record had no reason of transfer form or bed hold notice uploaded. Progress notes do not indicate that a written reason of transfer form or bed hold notice was given to R5 and/or POA.2. R63's face sheet shows an original admission date of 4/15/2018. R63's progress notes indicate the following: On 7/5/25 at 5:27 PM, Five minutes later, (R63) asked for Norco. When back to get Norco and while at the nursing station, received a call from 911 that (R63) had called them for difficulty breathing. Went back to the room to ask (R63) if she needed to go, 911 crew met (nurse) in the room while (R63)'s breathing treatment was still going on, but she has taken it off saying it did help. Told the nurse she needed a new type of breathing treatment. (R63) left facility about 5:15 PM via 911. Daughter notified via a voice note. On 7/5/25 at 11:05 PM, (R63) admitted for COPD (Chronic Obstructive Pulmonary Disease) Exacerbation. On 7/17/25 at 11:21 AM, (R63) was readmitted from hospital.On 8/8/25 at 5:21 AM, At 4:50 AM, (R63) complained of SOB (Shortness of Breath). Oxygen Saturation rate was 86% on 4 Liters/Minute oxygen inhalation via nasal cannula. Nebulizer treatment given with no effect. 911 was called. At 5:15 AM, (R63) left in care of fire department. Transported to (hospital) ER. Medical doctor notified. On 8/8/25 at 4:00 PM, (R63) admitted at (hospital) for COPD exacerbation. On 8/14/25 at 1:03 PM, (R63) readmitted from hospital.On 9/13/25 at 8:45 AM, (R63) requested for Xanax and Zofran.took to (R63)'s room for administration and stated, I think I am having a heart attack. Please call somebody. Vitals all within normal ranges. Oxygen saturation was 95% via nasal cannula. Not noted to be in any distress. (R63) sent out via 911 to ER. On 9/13/25 at 4:26 PM, (R63) returned from the ER with no new diagnosis or new orders.Review of R63's electronic medical record had no reason of transfer form or bed hold notice uploaded for all three transfers. Progress notes do not indicate that a written reason of transfer form or bed hold notice was given to R63 and/or POA.On 12/02/2025 at 11:02 AM, V2 (Director of Nursing) stated the facility doesn't give resident and/or their POA anything regarding the reason for transfer in writing. V3 stated the nurses only them or the paramedics the recent medication list, and labs. She stated maybe the marketing representative will give them the bed hold notice. V2 stated, We don't have time to give them a written notice or reason for transfer. We don't notify the ombudsman. This is the first time I'm hearing this. V2 was unable to provide any written reason of transfer forms, bed hold notices or documentation showing that the ombudsman was notified.Facility's policy titled Bed hold, Transfer, and Temporary Absence Policy (Review Date: 2/20/25) shows: 1. Resident Rights and Notifications-Residents and/or representatives will receive written notice of bed hold rights at admission and each time, a resident is transferred to the hospital or placed on leave. Notice must include coverage periods, private-pay options, and return rights. Updated notices will be issued if information changes. Procedure: 1. Staff provide the Bed hold notice at time of transfer, including duration and payment structure. 2. Medical record must include health status, transfer reason, notices, dates of communication, ombudsman notifications, and return needs.

Based on observation, interview and record review, the facility failed to assess, monitor and obtain a treatment order for a resident with a known pressure wound. This affects 1 of 4 residents (R89) reviewed for pressure ulcers. The findings include:R89's face sheet documents admission date of 11/24/25. Diagnoses include surgical amputation of left foot due to foot ulcer, type II diabetes mellitus, hyperlipidemia, depression, obstructive sleep apnea, hypertension, atherosclerotic heart disease, atrial fibrillation, congestive heart failure, peripheral vascular disease and osteoarthritis. MDS (Minimum Data Sheet) dated 11/3/25 documents R89 has intact cognitive functions. R89 is totally dependent on two staff for transfers and needs partial/moderate assistance with bed mobility. On 12/1/25 at 10:35 AM, incontinence care was being provided by V7 (Certified Nursing Assistant/CNA), V8 (CNA) and V9 (CNA). When R89 was positioned on his left side, an undated bordered foam dressing was observed on R89's sacrum. The wound dressing appeared old and was peeling off from R89's skin. V9 said she was going to take it off and inform the nurse to change it. V9 proceeded to take it off and went to the nurse. V4 (Wound Care Nurse) came to the room and immediately said that the dressing was not for pressure ulcer but was a pain patch and she will inform the nurse that it needs to be replaced. V4 was requested to look at R89's sacrum. V4 assessed R89's sacrum and said it looks like slough was present. She excused herself to get supplies for wound care. When V4 returned to R89's room, she proceeded to clean R89's sacral wound with normal saline. After cleansing, she measured the wound. R89's pressure wound measured 9 cm x 8.5 cm x 0.1 cm. V4 said there is a small area of the wound showing granulation but most of the wound was slough. V4 said she will inform R89's physician and will obtain orders for wound care. V4 said she was not informed of R89's wound on his sacrum. She said the last time she saw R89 was on 11/28/25 and wound was not present. V4 said she did a comprehensive skin assessment on 11/25/25 and wound on sacrum was not there.R89's hospital records immediately prior to admission were reviewed. The records showed R89 had a documented sacral pressure wound measuring 7 cm x 8.5 cm x 0.1, the wound was purplish, non-blanchable erythema, open deep tissue injury.On 12/2/25 at 11:00 AM, V13 (Wound Care Nurse Practitioner) said wounds should be assessed regularly, treatments should be monitored to increase chances of wound healing. V13 said if wound is not assessed and if proper wound treatment is not done, chances of the wound deteriorating increases.On 12/1/25 at 10:40 AM, review of R89's POS (Physician Order Sheet) showed no treatment order was included for R89's sacrum pressure wound. TAR (Treatment Administration Record) for November and December were reviewed and there was no treatment ordered for R89's sacrum wound. Care plan was reviewed, no care plan for right sacrum wound noted. Comprehensive Wound Assessment done by V4 on 11/25/25 documented wound due to below knee amputation of leg. V4's Progress Notes dated 11/25/25 at 4:24 PM documents that a body check was completed. R89's wound due to left lower extremity amputation was documented. No other wounds were documented. Facility's Pressure Ulcers/skin Breakdown-Clinical Protocol revised in March 2025 documents the following: Assessment and Recognition 3. The staff will examine the skin of a new admission for ulcerations or alterations in skin. Treatment/Management 1. The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alterations.

Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet the ADL (Activities of Daily Living) needs of the residents in the facility. This applies to all 79 residents residing in the facility. The findings include: The Facility Data Sheet dated February 6, 2025 shows the facility census as 79 residents. 1. On February 10, 2025 at 9:14 AM, R1 was lying in bed in her room. R1 said, My brief is wet. I was changed at 3:00 AM this morning. No one has changed me since they started at 6:00 AM when the next shift got here. I just have to wait my turn because they tell me they have a lot of people to take care of. R1 continued to say she is always sure she has an absorbent under pad to sit on in her bed so when she soaks through her incontinence brief, her bedding does not get soiled. V10 (CNA/Certified Nursing Assistant) was outside of R1's room. V10 said she was assigned to care for R1. V10 said she was assigned to care for twelve residents. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including rheumatoid arthritis, generalized anxiety disorder, insomnia, restless leg syndrome, major depressive disorder, anemia, and chronic pain syndrome. R1's MDS (Minimum Data Set) dated December 5, 2024 shows R1 has moderate cognitive impairment, requires supervision with eating, partial/moderate assistance with oral and personal hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R1 is frequently incontinent of urine, and always incontinent of stool. R1's care plan, initiated on May 9, 2024 shows: The resident is at risk for incontinence related to activity intolerance, has current bowel incontinence, has current urinary incontinence, impaired mobility, loss of peritoneal tone, physical limitations. Multiple interventions, initiated May 9, 2024 show: Clean peri-area with each incontinence episode. Check every two hours, upon request, as needed for incontinence . 2. On February 10, 2025 at 9:18 AM, R4 was sitting in his wheelchair by the nurse's station. R4 said he needed to use the restroom. At 9:25 AM, V6 (CNA/Staffing Coordinator) said R4 frequently states he has to use the restroom when his incontinence brief is already wet. V6 pushed R4 in his wheelchair back to his room to transfer R4 back to bed with V11 (CNA). As V6 and V11 lifted R4 from his wheelchair, the back of R4's sweatpants were soaking wet, approximately 12 inches in diameter about R4's buttocks. V6 said, [R1] drank a lot of water at breakfast this morning. V6 and V11 put R4 in his bed and started to remove his wet pants and incontinence brief. A strong odor of urine and stool was present. When V6 and V11 removed R4's incontinence brief, the brief was wet with urine and stool was present. V6 used disposable wipes to clean the stool from R4's buttocks and sacrum. R4 had an area of redness around his rectal area and sacrum, approximately six inches long by four inches wide. R4 said the area was tender when V6 was using disposable wipes to clean the area. V11 (CNA) said she was assigned to care for R4. V11 said she dressed R4 and provided incontinence care to him prior to breakfast. V11 said she was assigned to care for 12 residents, including two residents who required feeding assistance. The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including ALS (Amyotrophic Lateral Sclerosis), pain, insomnia, lung cancer, depression, and osteoporosis. R4's MDS dated [DATE] shows R4 has moderate cognitive impairment, require partial/moderate assistance with eating, substantial/maximal assistance with bed mobility and transfers between surfaces, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R4 is always incontinent of bowel and bladder. R4 did not have a pressure ulcer at the time of this MDS assessment. R4's care plan, initiated on March 8, 2024 shows: The resident is at risk for incontinence related to ALS, dementia, immobility. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review dated. Interventions: Clean peri-area with each incontinence episode. Check every two hours, upon request, as needed for incontinence. Wash, rinse, and dry perineum. Change clothing PRN (as needed) after incontinence episodes. 3. On February 10, 2025 at 12:09 PM, V15 (CNA) was passing meal trays to residents. Multiple call lights were going off, and V15 had to stop passing meal trays to attend to the needs of the residents with requests for assistance. V15 answered the call lights, and each resident asked, Where is my lunch tray? V15 explained to multiple residents she was in the process of passing lunch trays and would bring their trays as soon as possible. V15 said she was assigned to care for 14 residents on her shift. Of the 14 residents, 11 need me to help them with incontinence care and toilet hygiene, two of the residents need mechanical lifts to get out of bed, which means I need to find another CNA to help me, and one of the residents needs to be fed by me. The CNAs are also responsible for passing all meal trays to the residents and picking up the empty meal trays after lunch is finished. It is very difficult to do it all, but I always do my best. On February 6, 2025 at approximately 10:30 AM, V2 (DON/Director of Nursing) provided staffing schedules for the period of January 5, 2025 to March 1, 2025. V2 (DON) said, Our CNAs workday shift from 6:00 AM to 2:00 PM, PM shift from 2:00 PM to 10:00 PM, and night shift from 10:00 PM to 6:00 AM. We staff seven CNAs on day shift; four CNAs on the second floor, and three CNAs on the first floor. We staff six CNAs on PM shift; three CNAs on the second floor, and three CNAs on the first floor. We staff four CNAs on the night shift; two upstairs, and two on the first floor. Nurses workday shift from 7:00 AM to 3:30 PM, with two nurses on the second floor and two nurses on the first floor. PM shift is from 3:00 PM to 11:30 PM with two nurses on the second floor and two nurses on the first floor. Night shift is from 11:00 PM to 7:30 AM and is staffed with two nurses total; one upstairs and one on the first floor. On February 10, 2025 at approximately 10:00 AM and 10:50 AM, V6 (Staffing Coordinator/CNA) reviewed the staffing schedules for the period of January 1, 2025 to January 31, 2025. V6 said, Ideally, we would like to have seven CNAs in the facility for day shift so we can have four CNAs on the second floor where the resident care needs are greater, and three CNAs on the first floor. That just isn't always possible. I use agency staff to fill the gaps to get us up to six CNAs on day shift, but I have not been given permission to use agency staff to get us up to seven CNAs. There are a lot of days where we only have six CNAs for the day shift, and it is hard for the staff. Today we had a call-in, so I was pulled to the floor to work as a CNA so we can have six CNAs on the floor. There are a lot of residents with heavy needs. We do the best we can with what we have. We have to use two facility staff to do a transfer with a mechanical lift. V6 continued to say the facility census on February 6, 2025 was 79 residents and the facility had six CNAs working from 6:00 AM to 2:00 PM. V6 also said the ADL needs of the residents in the facility were the same on February 6 and February 10, 2025. During review of the staffing schedules with V6 (Staffing Coordinator/CNA), multiple day shifts were identified where the facility did not have 7 CNAs. The facility census and staffing numbers were confirmed with V6 (Staffing Coordinator/CNA) present. The staffing schedule shows the following dates/resident census/number of CNAs working from 6:00 AM to 2:00 PM: January 6, 2025 - 79 residents - 6 CNAs January 7, 2025 - 78 residents - 6 CNAs January 8, 2025 - 79 residents - 6 CNAs January 9, 2025 - 79 residents - 6 CNAs January 11, 2025 - 80 residents - 6 CNAs January 12, 2025 - 80 residents - 6 CNAs January 14, 2025 - 79 residents - 6 CNAs January 15, 2025 - 82 residents - 6 CNAs January 16, 2025 - 82 residents - 6 CNAs January 20, 2025 - 81 residents - 6 CNAs January 21, 2025 - 80 residents - 6 CNAs January 22, 2025 - 81 residents - 6 CNAs January 24, 2025 - 80 residents - 6 CNAs January 25, 2025 - 81 residents - 6 CNAs January 27, 2025 - 81 residents - 6 CNAs January 28, 2025 - 80 residents - 6 CNAs January 29, 2025 - 81 residents - 6 CNAs January 30, 2025 - 82 residents - 6 CNAs January 31, 2025 - 81 residents - 6 CNAs February 6, 2025 - 79 residents - 6 CNAs February 10, 2025 - 79 residents - 6 CNAs The facility provided a list of residents requiring feeding assistance, a list of residents requiring the use of a mechanical lift device for transfers between surfaces, a list of residents requiring substantial/maximal assistance or are dependent on facility staff for toilet hygiene, a facility census, and CNA staffing assignments for February 6, and 10, 2025. The resident census and resident ADL needs were similar on February 6 and 10, 2025. On February 10, 2025 from 6:00 AM to 2:00 PM, V11 (CNA) was assigned to care for 12 residents. Ten of the residents assigned to V11 required staff assistance with toilet hygiene, 4 residents required mechanical lifts for transfers, and 2 residents required feeding assistance. On February 10, 2025 from 6:00 AM to 2:00 PM, V12 (CNA) was assigned to care for 12 residents. Ten of the residents assigned to V12 required staff assistance with toilet hygiene, 3 residents required mechanical lifts for transfers, and 2 residents required feeding assistance. On February 10, 2025 from 6:00 AM to 2:00 PM, V6 (Staffing Coordinator/CNA) was assigned to care for 12 residents. Seven of the residents assigned to V6 required staff assistance with toilet hygiene, and one resident required a mechanical lift device to transfer between surfaces. On February 10, 2025 from 6:00 AM to 2:00 PM, V16 (CNA) was assigned to care for 14 residents. Eleven residents assigned to V16 required staff assistance with toilet hygiene, 4 residents required a mechanical lift device to transfer between surfaces, and 2 residents required feeding assistance. On February 10, 2025 from 6:00 AM to 2:00 PM, V15 (CNA) was assigned to care for 14 residents. Eleven residents assigned to V15 required staff assistance with toilet hygiene, 2 residents required the use a mechanical lift device to transfer between surfaces, and 1 resident required feeding assistance. On February 10, 2025 from 6:00 AM to 2:00 PM, V17 (CNA) was assigned to care for 15 residents. Eight of the residents assigned to V17 were dependent on facility staff for toilet hygiene, 1 resident required a mechanical lift device for transfers between surfaces, and 1 resident required feeding assistance. The Facility Assessment Tool, updated on 09/20/24 and reviewed by the QAA/QAPI (Quality Assessment and Assurance/Quality Assurance Performance Improvement on 12/11/24 shows the average daily census for the facility is 74 to 78 residents. The Facility Assessment Tool continues to show: Staffing Plan: Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Licensed nurses providing direct care: 10 to 17 total number needed or average or range. Nurse aides: 24 to 26 CNAs. The Facility Assessment Tool continues to show: Describe your general staffing plan to ensure that you have sufficient staff to meet the needs of the residents at any given time. Consider if and how the degree of fluctuation in the census and acuity levels impact staffing needs. For example: Licensed Nurses: Plan: DON full-time days, ADON (Assistant Director of Nursing/Restorative: 1 LPN (Licensed Practical Nurse) Full-time days, MDS: 1 MDS RN (Registered Nurse) full-time days. Wound Care: 1 LPN Full-time days. RN or LPN Charge Nurse: 1 for each shift, 1 nurse per shift is the charge nurse. Staffing ratio 1 LPN or RN for days and evening shift for 20 residents. The Facility Assessment Tool continues to show the staffing ratio of direct care staff (CNAs) to residents is one CNA to ten residents for day and PM shift, and one CNA to 20 residents for night shift. It will be checked against the state requirements as well as evaluated daily based on census and acuity in the facility and per floor.

Based on observation and interview, the facility failed to provide a clean, homelike environment when it failed to provide window shades, or equivalent, that are in good repair, without stains or tears. This applies to 13 of 18 residents (R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18) reviewed for lack of window shades/curtains and homelike environment in the sample of 18. The findings include: 1. On February 6, 2025 at 9:26 AM, R6 and R7 were sitting in their room. The window in their room had temporary, pleated paper shades over the window. The paper shades were torn. Plastic clips were in place to hold the shade open approximately 12 inches from the bottom of the windowsill. The residents said they are unable to raise and lower the shades to a height of their liking, so the shades remain held open with the plastic clips, in the same position. 2. On February 6, 2025 at 9:30 AM, R8 and R9 were sitting in the room they share at the facility. R8 and R9's room has a large window, approximately 5 feet wide by 5 feet high. R8 and R9's window faces the courtyard/patio of the facility. R8 and R9's window did not have window coverings, including shades, blinds, or curtains. R8 and R9 could not be interviewed due to their cognitive status. On February 10, 2025 at 9:30 AM, R8 and R9 were not sitting in their room. R8 and R9's room did not have window coverings, including, shades, blinds, or curtains. 3. On February 6, 2025 at 9:34 AM, R10 and R11 were sitting in their room. The window in R10 and R11's room had temporary, pleated paper shades over the window. The paper shades were torn in multiple places. The paper shades did not have plastic clips in place to raise or lower the shade to see outside the window. 4. On February 6, 2025 at 9:21 AM, R12 was lying in bed in her room. R12 could not be interviewed due to her cognitive status. R12's room had a large window, approximately 5 feet wide by 5 feet high. R12's window did not have window coverings, including shades, blinds, or curtains. 5. On February 6, 2025 at 9:36 AM, R13 and R14 were sitting in their room. R13 and R14's window was covered by temporary, pleated paper shades. The bottom of the shade was approximately 12 inches from the bottom windowsill and was being held in place with plastic clips. R14 was sitting on the edge of his bed, next to the window. R14 was bent over and trying to look out the window, through the 12-inch opening between the bottom of the shade and the windowsill. R14 said, These shades don't work. You can't make them go up and down, so if I want to look outside, I must bend over to see out. It makes the room feel dark all day. 6. On February 6, 2025 at 9:28 AM, R15 and R16 were sitting in their room. R15 and R16's window was covered by temporary, pleated papers shades. The paper shades were torn in multiple places and did not have plastic clips in place to raise or lower the shades to see outside. 7. On February 6, 2025 at 9:25 AM, R17 and R18 were sitting in their room. R17 and R18's window was covered by a large shade. The window shade was an ivory color. The bottom two feet of the window shade was heavily stained with a dark brownish, red substance. On February 6, 2025 at 11:22 AM, V5 (Maintenance Director) said, They were in the middle of a remodeling update here, but then stopped because of money issues. They are thinking of starting it up in the next six months. V9 (Former Administrator) had started the remodeling, but then never finished it. We had a quote for over $4,000 for window treatments, so he did not go through with it. We had an administration change about six months ago, but we have not restarted the remodeling. V5 continued to say it has been six months or longer that resident rooms have been without permanent window shades.

Based on observation, interview, and record review, the facility failed to provide timely incontinence care. This applies to 2 of 3 residents (R1 and R4) reviewed for timely incontinence care in the sample of 18. The findings include: 1. On February 10, 2025 at 9:14 AM, R1 was lying in bed in her room. R1 said, My brief is wet. I was changed at 3:00 AM this morning. No one has changed me since they started at 6:00 AM when the next shift got here. I just have to wait my turn because they tell me they have a lot of people to take care of. V10 (CNA/Certified Nursing Assistant) was outside of R1's room. V10 said she was assigned to care for R1. V10 said she was assigned to care for twelve residents. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including rheumatoid arthritis, generalized anxiety disorder, insomnia, restless leg syndrome, major depressive disorder, anemia, and chronic pain syndrome. R1's MDS (Minimum Data Set) dated December 5, 2024 shows R1 has moderate cognitive impairment, requires supervision with eating, partial/moderate assistance with oral and personal hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R1 is frequently incontinent of urine, and always incontinent of stool. R1's care plan, initiated on May 9, 2024 shows: The resident is at risk for incontinence related to activity intolerance, has current bowel incontinence, has current urinary incontinence, impaired mobility, loss of peritoneal tone, physical limitations. Multiple interventions, initiated May 9, 2024 show: Clean peri-area with each incontinence episode. Check every two hours, upon request, as needed for incontinence . 2. On February 10, 2025 at 9:18 AM, R4 was sitting in his wheelchair by the nurse's station. R4 said he needed to use the restroom. At 9:25 AM, V6 (CNA/Staffing Coordinator) said R4 frequently states he has to use the restroom when his incontinence brief is already wet. V6 pushed R4 in his wheelchair back to his room to transfer R4 back to bed with V11 (CNA). As V6 and V11 lifted R4 from his wheelchair, the back of R4's sweatpants were soaking wet, approximately 12 inches in diameter about R4's buttocks. V6 said, [R1] drank a lot of water at breakfast this morning. V6 and V11 put R4 in his bed and started to remove his wet pants and incontinence brief. A strong odor of urine and stool was present. When V6 and V11 removed R4's incontinence brief, the brief was wet with urine and stool was present. V6 used disposable wipes to clean the stool from R4's buttocks and sacrum. R4 had an area of redness around his rectal area and sacrum, approximately six inches long by four inches wide. R4 said the area was tender when V6 was using disposable wipes to clean the area. V11 (CNA) said she was assigned to care for R4. V11 said she dressed R4 and provided incontinence care to him prior to breakfast. V11 said she was assigned to care for 12 residents, including two residents who required feeding assistance. The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including ALS (Amyotrophic Lateral Sclerosis), pain, insomnia, lung cancer, depression, and osteoporosis. R4's MDS dated [DATE] shows R4 has moderate cognitive impairment, require partial/moderate assistance with eating, substantial/maximal assistance with bed mobility and transfers between surfaces, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R4 is always incontinent of bowel and bladder. R4 did not have a pressure ulcer at the time of this MDS assessment. R4's care plan, initiated on March 8, 2024 shows: The resident is at risk for incontinence related to ALS, dementia, immobility. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review dated. Interventions: Clean peri-area with each incontinence episode. Check every two hours, upon request, as needed for incontinence. Wash, rinse, and dry perineum. Change clothing PRN (as needed) after incontinence episodes.

Based on observation and interview the facility failed to ensure electrical wires are not left exposed, near a resident's metal bed frame. This applies to 1 of 4 residents (R1) reviewed for safe environment in the sample of 18. The findings include: On February 6, 2025 at 9:15 AM, R1 was lying in bed in her room. The headboard of R1's bed was up against the wall of her room. The wall behind R1's bed had multiple areas of chipped plaster and paint. On the wall behind R1's headboard, approximately 4 inches from the floor, an electrical outlet box appeared damaged. The outlet box was hanging off the wall. The outlet box was open, and electrical wires were hanging outside of the outlet box. The electrical wires had multiple electric wire connectors in place on the ends of the electrical wires. The exposed electric wires were approximately two to four inches from R1's metal bed frame. R1 said, Oh, every time they boost me in the bed, the whole bed moves and bangs into the wall behind my bed. I know they hit that outlet with my bed, because I hear the staff say, Oh darn, we hit that outlet again. R1 continued to say she is dependent on facility staff to reposition her in bed, and remains in her bed at all times, which is her preference. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including rheumatoid arthritis, generalized anxiety disorder, insomnia, restless leg syndrome, major depressive disorder, anemia, and chronic pain syndrome. R1's MDS (Minimum Data Set) dated December 5, 2024 shows R1 has moderate cognitive impairment, requires supervision with eating, partial/moderate assistance with oral and personal hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). R1 is frequently incontinent of urine, and always incontinent of stool. On February 6, 2025 at 11:22 AM, V5 (Maintenance Director) said, I have constant issues with a hanging outlet in [R1's] room. It is behind her bed and the staff keep hitting the outlet with her bed when they boost [R1]. My plan is to shorten that outlet where it won't keep getting knocked off the wall. As long as the box is intact, there is no way she can get electrocuted. The last time it was reported to me was three months ago. During this interview, V5 was made aware of the electrical outlet hanging off the wall with exposed wiring in R1's room by this surveyor. On February 6, 2025 at 2:57 PM, R1 was lying in bed in her room. The broken electrical outlet and exposed wiring continued to be an issue, with no changes noted in the electrical outlet. On February 10, 2025 at 9:37 AM, V5 (Maintenance Director) said he was able to cover the electrical outlet in R1's room. V5 said he had not shortened the outlet or put any interventions in place to ensure the electrical outlet could not become damaged again during repositioning of R1. V5 said, I wouldn't be surprised if that outlet is broken again.

Based on observation, interview, and record review, the facility failed to follow their water management plan. The facility also failed to follow their policy regarding catheter care to prevent infection and to follow Enhanced Barrier Precautions. The facility also failed to perform hand hygiene and glove changes during provisions of care. This applies to all 70 residents residing in the facility. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated September 9, 2024, showed the facility census was 70 residents. The facility's Water Management Program for Prevention of Legionella Growth dated June 27, 2023, showed Purpose: To identify and reduce the risk of Legionella growth and spread . Preventative maintenance will be performed as applicable: The following will be verified and documented at least once weekly: -The domestic hot water boiler/storage tanks verified to be set between 140 to degrees Fahrenheit. -Thermostat indicating the temperature of water entering the circulating system at the mixing valve is 120 Fahrenheit or above. -Eye wash stations will be inspected and flushed weekly. -Ice machines will be inspected and cleaned internally at least monthly and as needed for leakages or contamination. -Cooling tower (if applicable) will be inspected at least weekly to ensure proper functioning and chemical distribution. -Weekly sanitizing of medical devices such as CPAP (Continuous Positive Airway Pressure), hydrotherapy, etc. Environmental Services will monitor the identified areas of risk per guidelines above and implement corrective action as indicated . On September 10, 2024, at 2:56 PM, V10 (Maintenance Director) said he does not perform weekly checks and record the temperatures of the hot water boiler/storage tank. V10 continued to say he doesn't flush the eye wash stations weekly. V10 said he checks the flow of the eye wash stations once a month. V1 continued to say he cleans the ice machine every one to two months. V10 said he inspects the cooling tower monthly. The facility does not have documentation to show the temperatures of the hot water boiler/storage tanks and thermostat at the mixing valve was checks at least once weekly. On September 10, 2024, at 3:38 PM, V1 (Administrator) said V10 should be following the facility's water management program for Legionella, including documenting the water temperatures weekly. 2. R48's EMR (Electronic Medical Record) showed R48 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, dementia, depression, anxiety disorder, arthropathy, and generalized muscle weakness. R48's MDS (Minimum Data Set) dated June 29, 2024 showed R48 had moderately impaired cognition, was always incontinent of bowel and bladder and was dependent on staff for incontinence care. R48's care plan showed R48 was at risk for incontinence related to inactivity, Alzheimer's disease, confusion, and dementia. The interventions included check and change every two hours and as needed. Staff were to wash, rinse, and dry perineum with each incontinence episode. On September 11, 2024, at 9:15 AM, V4 (Certified Nursing Assistant/CNA) and V5 (CNA) were in the room of R48 and R22 making their beds wearing gloves. R48 was brought back into her room from breakfast. V4 removed her gloves, grabbed a new pair of gloves, and without hand hygiene put on the gloves. V5 finished making V22's bed, removed her gloves, grabbed new gloves, and put on gloves without hand hygiene. V4 placed a gait belt around R48 and V4 and V5 transferred R48 back to bed. R48's pants were removed, and incontinence brief was opened. V5 explained to R48 that she was going to clean her up and change her incontinence brief. V5 used disposable wipes and cleaned all areas of the front perineal area. V5 helped R48 turn onto her left side facing V4 and it was noted she had a small bowel movement. V4 wearing the same gloves used to clean the front perineal area, used disposable wipes to clean the buttocks area. V5 removed her gloves, went to the bathroom, and washed her hands and put on new gloves to apply barrier cream to R48's buttocks. With the same glove used to apply barrier cream, V5 grabbed the clean brief and pulled the brief up in between R48's legs, V4 fastened the brief, V5 removed her gloves and without hand hygiene put on new gloves and fixed R48's covers on the bed. V5 removed her gloves and took the garbage out. V5 came back to the room with a bag for the soiled linen that was laying on the floor. V4 had removed her gloves and set them on the top of a box of gloves, V5 asked V4 to pick up the soiled linen and put in the bag. V4 picked up her gloves off the top of the box of gloves and put them on. V4 then picked up the soiled linen off the floor and placed them into the bag that V5 was holding. V4 removed her gloves and gathered supplies to provide incontinence care to R48's roommate, R22. 3. R22's EMR showed R22's most recent admitted to the facility was May 15, 2021. R22's diagnoses included epilepsy, generalized muscle weakness, overactive bladder, cognitive communication deficit, major depression, and abnormalities of gait and mobility. R22's MDS dated [DATE] showed R22 had moderately impaired cognition, was always incontinent of bladder, frequently incontinent of bowel, and was dependent on staff for incontinence care. R22's care plan showed R22 had the potential for skin impairment related to fragile skin, immobility, and incontinence. Interventions included keep skin clean and dry, use lotion on dry skin. On September 11, 2024 at 9:49 AM, V4 (CNA) and V5 (CNA) had just finished providing incontinence care to roommate R48 and now had prepared to check and change R22. V5 closed the blinds and pulled the curtain in between the two beds. V4 put on gloves, no hand hygiene, placed gait belt on R22 and explained to her what they were going to do. Once R22 was laid down bed, her pants were removed. V4 used disposable wipes and cleaned all area of the front perineal area. V4 turned R22 onto her left side, and without removing her gloves or performing hand hygiene, cleaned the buttocks, wiping from front to back. After cleaning her buttocks V4 removed her gloves, and said she was going to wash her hands in the bathroom. V4 put on new gloves and applied barrier cream to R22's buttocks. V5 grabbed R22's pants and put them on R22 while V4 removed her gloves and without hand hygiene, put on new gloves. V4 helped V5 pull up R22's pants, pull R22 up higher in the bed, and then covered her with her blankets. 4. The EMR (Electronic Medical Record) showed that R64, a [AGE] year-old with diagnoses that includes but not limited to type 2 diabetes mellitus, malignant neoplasm of the prostate, history of urine infection with identified ESBL (Extended Beta Lactamase Spectrum) microorganism, osteoarthritis, congestive heart failure, anemia, diabetic neuropathy, lack of coordination, and abnormalities of gait and mobility. R64 was admitted to the facility on [DATE]. The EMR also showed that R64 was on EBP (Enhanced Barrier Precautions). The MDS (Minimum Data Set) dated August 2,2024 showed that R64 was cognitively intact. On September 9, 2024 at 9:35AM, V7 (CNA) assisted R64 to stand up. While R64 was in a standing position, V7 pulled down R64 pants to check for soiling. V7 assisted R64 back to seating position and said she will get V6 (CNA assigned to R64) to clean R64. V7 did not perform hand hygiene prior to leaving the room and touching R64. V6 came and took R64 to the bathroom. V6 removed the urinary drainage bag from the privacy bag that was hanging behind R64's wheelchair. V6 placed the urinary drainage bag on the floor, and she assisted R64 to get up from his wheelchair and R64 positioned standing behind the toilet seat. V6 wiped R64's penile area with moistened wipes. V6 then left R64's room without performing hand hygiene and V8 (Registered Nurse) returned 5 minutes later. V8 came back to R64's room. V8 then applied an ointment to R64's private area. V8 did not perform hand hygiene. V6 was then noted to step on the urinary drainage bag that was still located on the floor. On September 11, 2024 at 9:30 A.M., V3 (Assistant Director of Nursing) said that R64 was on Enhance Barrier Precaution due to indwelling urinary catheter, history of ESBL and a wound on R64's great toe. V3 said that a gown must be used when V6 and V8 had provided direct care to R64. V3 also said that to prevent infection, it is the facility's practice not to placed urinary catheter drainage bag on the floor. V3 added that staff should have done handwashing/hand hygiene in between providing resident's care, in between care task, task, touching dirty to clean areas and in between gloves changing. 5. On September 9, 2024 at 10:15 A.M., R4 was lying in bed. V6 and V7 (CNAs) were observed providing incontinence care to R4. R4's incontinence brief was soaked with urine. V7 wiped R4's groins, and midline opening of labial folds. V6 wiped R4's rectal area; apply skin barrier, put on a clean brief, fastened the brief; did not changed gloves after the incontinence care and prior to putting clean brief and skin barrier. R4 was then transferred from bed to wheelchair with used of mechanical transfer lift device. V6 and V7 have both removed their gloves, no hand hygiene, then put on a pair of gloves without hand hygiene prior to transferring R4 to the wheelchair. The EMR showed that R4, an [AGE] year-old female with diagnoses of type 2 diabetes mellitus, dementia, and anemia. The undated facility's policy and procedure for urinary catheter care showed that urinary indwelling catheter drainage bag should be off the floor to prevent cross contamination and infection. The undated policy for hand washing/hand hygiene showed hand hygiene be implemented including but not limited to before and after direct contact with residents; before and after handling invasive device such as urinary catheter, and before donning on gloves. The undated policy for Enhanced Barrier Precautions showed to wear PPE (such as gown, gloves, mask) when providing resident's care. 15845 45303

Based on interview and record review, the facility failed to follow their policy to offer and administer the COVID-19 vaccine to residents. This applies to 4 of 5 residents (R1, R22, R32, and R39) reviewed for vaccinations in the sample of 18. The findings include: 1. The EMR (Electronic Medical Record) showed R1 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, asthma, alcoholic cirrhosis of the liver, heart failure, and type 2 diabetes mellitus. R1's Immunization Report showed R1's most recent COVID-19 vaccine was received on September 27, 2022. On September 11, 2024, at 1:37 PM, V11 (Nurse Consultant) said the facility follows CDC (Centers for Disease Control and Prevention) recommendations for COVID-19 vaccinations. V11 continued to say R1 should have been offered the 2023-2024 COVID-19 vaccine. The facility does not have documentation to show R1 was offered the 2023-2024 updated COVID-19 vaccine. 2. The EMR showed R22 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including epilepsy, anemia, hyperlipidemia, atherosclerotic heart disease, transient ischemic attack, and cerebral infarction. R22's Immunization Report showed R22's most recent COVID-19 vaccine was received on October 27, 2022. On September 11, 2024, at 1:37 PM, V11 said R22 should have been offered the 2023-2024 COVID-19 vaccine. The facility does not have documentation to show R22 was offered the 2023-2024 updated COVID-19 vaccine. 3. The EMR showed R32 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including rheumatoid arthritis, long term use of systemic steroids, type 2 diabetes mellitus, and hypertension. R32's Immunization Report showed R32's most recent COVID-19 vaccine was the COVID-19 bivalent booster on January 19, 2023. On September 11, 2024, at 1:37 PM, V11 said R32 should have been offered the 2023-2024 COVID-19 vaccine. The facility does not have documentation to show R32 was offered the 2023-2024 updated COVID-19 vaccine. 4. The EMR showed R39 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, chronic kidney disease, and peripheral vascular disease. R39's Immunization Report showed R39's most recent COVID-19 vaccination was received on February 18, 2022. On September 11, 2024, at 1:37 PM, V11 said R39 should have been offered the 2023-2024 COVID-19 vaccine. The facility does not have documentation to show R39 was offered the 2023-2024 updated COVID-19 vaccine. The facility's policy titled COVID-19 Vaccine Policy dated October 2023, showed Policy: All residents and employees who have no medical contraindications to the vaccine will be offered the vaccine/booster annually to discourage and promote the benefits associated with vaccinations against COVID-19. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (residents' legal representatives); for example, risk factors that have been identified with specific age groups or individuals with risk factors such as allergies or pregnancy. Facility will encourage the COVID-18 vaccinations as per guidelines. Procedure: 1. The vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized . 7. Administration of the vaccine will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination . The CDC's COVID-1 Vaccine Information Statement dated October 19, 2023, showed .COVID-19 Vaccine: Updated (2023-2024 Formula) COVID-19 vaccine is recommended for everyone six months of age and older . Everyone [AGE] years and older should get one dose of an FDA (Food and Drug Administration) approved, updated 2023-2024 COVID-19 vaccine. If you have received a COVID-19 vaccine recently, you should wait at least eight weeks after you most recent dose to get the updated 2023-2024 COVID-19 vaccine .

Based on observation, interview, and record review the facility failed to ensure indwelling urinary catheter was anchored to prevent the catheter from being pulled, tugged, and avoid catheter related trauma. This applies to 1 of 1 resident (R64) reviewed for catheter care in the sample of 18. The Findings include: The EMR (Electronic Medical Record) showed that R64, a [AGE] year-old with diagnoses that includes but not limited to type 2 diabetes mellitus, malignant neoplasm of the prostate, history of urine infection with identified ESBL (Extended Beta Lactamase Spectrum) microorganism, osteoarthritis, congestive heart failure, anemia, diabetic neuropathy, lack of coordination and abnormalities of gait and mobility. R64 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) dated 8/2/24, showed that R64 was cognitively intact. On 9/11/24 at 9:45 AM, R64 was complaining of pain and discomfort in his penis area. R64 was observed with an indwelling urinary catheter draining concentrated urine. R64 was noted with moderate amount of fresh blood around the tip of the penis, and noted a fresh blood that had soaked through the incontinence brief that R64 was wearing. The urinary catheter tubing was not secured and was freely dangling in between R64's legs. The urinary catheter was noted to have been pulled out approximately 4 inches due to the color delineation. The catheter tubing that was pulled out showed a very pale light-yellow color and the remaining color of the catheter tubing was darker yellow. V8 (Registered Nurse) confirmed that the urinary catheter was pulled out and it should have been secured and anchored with a strap to his inner thigh prevent the catheter from being pulled or tugged and may have caused the bleeding. On 9/11/2024 at 9:30 AM, V3 (Assistant Director of Nursing) said that the indwelling catheter tubing should be secured with an anchor device, to prevent the indwelling catheter tubing from being pulled or tugged and avoid catheter related trauma. The care plan dated 8/3/24 showed that R64 has an indwelling catheter, and goal was to maintain comfort and free from infection. Interventions included assessment and notifying physician for any changes. The undated facility's policy and procedure for urinary catheter care showed that urinary indwelling catheter should be secured with a strap to prevent from being pulled and tugged. The policy also showed that this policy be implemented for the purpose of preventing catheter -associated infections, trauma and to maintain comfort of the resident.

Based on interview and record review, the facility failed to follow their policy to offer and administer pneumococcal vaccines in accordance with CDC (Centers for Disease Control and Prevention) guidelines. This applies to 3 of 5 residents (R1, R22, and R32) reviewed for vaccinations in the sample of 18. The findings include: 1. The EMR (Electronic Medical Record) showed R1 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, asthma, alcoholic cirrhosis of the liver, heart failure, and type 2 diabetes mellitus. R1's Informed Consent for Vaccinations dated January 16, 2021, showed R1 consented to receive pneumococcal vaccinations. R1's Immunization Report showed R1 received the PPSV23 (23-valent Pneumococcal Polysaccharide Vaccine) on January 18, 2021. On September 11, 2024, at 1:37 PM, V11 (Nurse Consultant) said the facility follows CDC guidelines for pneumococcal vaccine timing and R1 should have been offered a second pneumococcal vaccine after receiving the PPSV23. The facility does not have documentation to show R1 was offered or received another pneumococcal vaccine. 2. The EMR showed R22 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including epilepsy, anemia, hyperlipidemia, atherosclerotic heart disease, transient ischemic attack, and cerebral infarction. R22's Informed Consent for Vaccinations dated October 18, 2020, showed R22's Resident Representative consented for R22 to receive the pneumococcal vaccinations. R22's Immunization Report showed R22 received the PPSV23 on December 15, 2020. On September 11, 2024, at 1:37 PM, V11 said R22 should have been offered a second pneumococcal vaccine after receiving the PPSV23. The facility does not have documentation to show R22 was offered or received another pneumococcal vaccine. 3. The EMR showed R32 was a [AGE] year-old resident, admitted to the facility on [DATE], with multiple diagnoses including rheumatoid arthritis, long term use of systemic steroids, type 2 diabetes mellitus, and hypertension. R32's Pneumococcal Vaccine Information and Consent dated October 2, 2023, showed R32 consented to receiving the pneumococcal vaccine. R32's Immunization Report showed R32 received the PCV13 (13-valent Pneumococcal Conjugate Vaccine) on June 15, 2012. On September 11, 2024, at 1:37 PM, V11 said R32 should have received a second pneumococcal vaccine since she consented to receiving the vaccine. The facility does not have documentation to show R32 received a second pneumococcal vaccine. The facility's policy titled Pneumococcal Vaccine dated April 2022, showed Policy Statement: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation: .7. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. The CDC's Pneumococcal Vaccine Timing for Adults dated April 1, 2022, showed For those who previously received PPSV23 but who have not received any pneumococcal conjugate vaccine (e.g., PCV13, PCV15 (15- valent Pneumococcal Conjugate Vaccine), PCV20 (20-valent Pneumococcal Conjugate Vaccine)). You may administer one dose of PCV15 or PCV20. Regardless of which vaccine is used (PCV15 or PCV20): the minimum interval is at least one year. Their pneumococcal vaccinations are complete . Pneumococcal vaccine timing for adults who previously received PCV14 but who have not received all recommend doses of PPSV23 . Adults [AGE] years or older without an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant: CDC recommends one dose of PPSV23 at age [AGE] years or older. Administer a single dose of PPSV23 at least one year after PCV13 was received. Their pneumococcal vaccinations are complete .

Based on interview and record reviews, the facility's most recent arbitration agreements failed to include language that stated signing the agreement was not a condition/requirement to admission or receiving care at the facility. The facility also failed to update previously signed arbitration agreements which did not include language that: 1. The arbitration agreement could be rescinded in 30 days. 2. An arbitrator and meeting location would be mutually decided between parties. This applies to all 70 residents residing in the facility. The findings include: Facility Long-Term Care Facility Application for Medicare and Medicaid form, dated September 9, 2024, shows the facility census was 70 residents. On September 10, 2024 at 9:54 AM, V12 (Admissions Coordinator) stated the arbitration agreement is offered to every resident upon admission to the facility as a part of the admission contract. On September 10, 2024 at 9:57 AM, V1 (Acting Administrator) stated the facility arbitration agreement was imbedded in the facility admission contract. V1 stated the facility updated their contracts to include language that allows a resident to rescind the arbitration agreement within 30 days of signing as well as included language that an arbitrator and meeting location would be mutually decided between parties. V1 reviewed the updated facility arbitration agreement and stated the contract did not include language that signing the agreement was not a condition/requirement for admission or receiving care at the facility. Review of R65's signed arbitration agreement, dated September 10, 2024, showed the agreement failed to include language that signing the agreement was not a condition/requirement to admission or receiving care at the facility. Review of R26's signed arbitration agreement, dated June 25, 2022, and R51's signed arbitration agreement, dated September 26, 2022, showed the arbitration agreements failed to include the following language in the agreements: 1. Signing the agreement was not a condition/requirement to admission or receiving care at the facility 2. The agreement could be rescinded in 30 days 3. An arbitrator and meeting location would be mutually decided between parties.

There are multiple deficient practice statements. A. Based on observation, interview and record review the facility failed to ensure water temperatures in resident bathrooms were maintained at a safe level to prevent potential resident injury. This failure resulted in the water in five residents' bathrooms measuring 150(+) degrees Fahrenheit, having the potential to cause third degree burns within 1-2 seconds, at 12:40 PM on 11/13/23. This applies to 5 of 5 residents (R16, R17, R38, R53 and R55) reviewed for safety in the sample of 22. B. Based on observation, interview and record review the facility failed to ensure a resident on a mechanically altered diet was safely assisted to eat for 1 of 22 residents (R39) reviewed for safety in the sample of 22. The findings include: A. The Immediate Jeopardy began on 11/13/23 at 12:40 PM when V3 (Maintenance Director) and Surveyor checked the water temperature in 5 residents' bathrooms on the second floor of the facility. Using the facility's thermometer, the temperatures measured 150.1-150.2 degrees Fahrenheit. V1 (Administrator) was notified of the Immediate Jeopardy on 11/15/23 at 10:45 AM. The Surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 11/15/23 at 2:15 PM; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. On 11/13/23 at 12:40 PM V3 (Maintenance Director) and Surveyor used the facility's thermometer to measure the water temperatures in the bathroom sinks of R16, R17, R38, R53 and R55. R16's water measured 150.1 degrees Fahrenheit, R17's water measured 150.1 degrees Fahrenheit, R38 and R53's water measured 150.2 degrees Fahrenheit and R55's water measured 150.2 degrees Fahrenheit. R16's Physician's Order Sheet (POS) dated November 2023 shows that R16 has diagnoses including Vascular Dementia with Behavioral Disturbance. R16's MDS (Minimum Data Set) of 8/10/23 shows that R16 has severe cognitive impairment. On 11/13/23 and 11/14/23 R16 was observed propelling herself in her wheelchair in her room and in the hallway outside of her room. R17's POS dated November 2023 shows that R17 has diagnoses including Dementia and Anxiety. R17's MDS of 9/17/23 shows that she has Moderate Cognitive Impairment and requires only supervision for locomotion on the unit. R38's POS dated November 2023 shows that R38 has diagnoses including Traumatic Subdural Hemorrhage and Dementia. R38's MDS of 8/17/23 shows that he has moderate cognitive impairment and requires only supervision for locomotion on the unit. R53's POS dated November 2023 shows that R53 has diagnoses including Cognitive Communication Deficit and Lack of Coordination. R53's MDS of 8/29/23 shows that he has Moderate Cognitive Impairment and requires only supervision for locomotion on the unit. R55's POS dated November 2023 shows that R55 has a diagnosis of Dementia. R55's MDS of 9/12/23 shows that he has severe cognitive impairment and requires only supervision for locomotion on the unit. On 11/13/23 at 12:40 PM V3 (Maintenance Director) stated, Oh wow, that is too hot. I do random room checks every day- just random rooms throughout the building. I've been getting 98-110 degrees Fahrenheit every day. The mixing valve is reading about 105-108 degrees Fahrenheit. We had a problem about 4-5 months ago that upstairs was not getting enough hot water and we had the mixing valve replaced. I will need to call the vendor and have them come out and take a look. On 11/13/23 at 12:55 PM V3 and Surveyor went to the basement mechanical room and observed the mixing valve dial on the hot water boiler system. The mixing valve dial showed the water temperature at approximately 108 degrees Fahrenheit. On 11/13/23 at 1:56 PM V3 stated, I ran the shower upstairs for about 10 minutes and it dumped all that hot water. This is an old building. I don't know what the problem is. I still have to call the plumber to come out and take a look. This has never happened before. We had issues with the mixing valve but that was replaced. The water temperatures are good now. On 11/13/23 at 3:53 PM V1 (Administrator) stated, This is an old building. This is not something that happens all the time. We can have (Vendor) come back out and look at it. The staff use the sinks all the time. I have never heard any complaints about it before. I can try to get someone here tomorrow to look at it. Since they came out and did the work (9/28/23), we haven't had a problem. I understand that it has to be treated in a special way. We can check the water temps throughout the building in the meantime while we are waiting for plumber to come. On 11/14/23 at 8:19 AM V7 (Certified Nursing Assistant/CNA) stated, If you turn it on and let it run like early in the morning it sometimes, like once or twice, has gotten really hot. I can't even touch it. But then you can adjust it by turning on the cold. On 11/14/23 at 8:43 AM V8 (CNA) stated, We can run it sometimes it takes 15-20 minutes to heat up. Once in a blue moon it gets too hot, depending on how many showers we have. The more showers the better it gets because it is constantly running. It is an old building. Sometimes it won't get hot at all. On 11/14/23 at 9:10 AM V9 (CNA) stated, (The water) can get too warm, if you turn it too much, too hot or too cold, it gets pretty hot. (I) have to finesse it to get it to the right temperature. Not sure if it is the plumbing, it is an old building. We couldn't give showers because it was too hot a while ago. I told maintenance and I filled out a form. On 11/14/23 at 9:14 AM V10 (CNA) stated, On my second day working, the shower room was not working, there was no handle. The hot was too hot. I had to mix with cold water. On 11/14/23 at 12:20 PM V5 (Plumber), V3 (Maintenance Director) and Surveyor checked the water temperatures in R17's and R55's rooms. The temperatures measured 105 degrees Fahrenheit and 104 degrees Fahrenheit. V3 then stated, We did have a power outage on Friday, and I had to reset the breakers yesterday. I did that around 1:00 PM, after we checked the water. (After the hot water temperatures measured 150(+) degrees Fahrenheit.) V5 stated, It is possible that something got caught in the [NAME] Valve (mixing valve). That can be very touchy, and this could be very difficult to figure out where the problem is. V5 observed the dial on the mixing valve that showed the water temperature at just below 110 degrees Fahrenheit. V5 stated that the boiler is at 140 degrees Fahrenheit. V5 stated, I am at a loss. Without being here when it happened, I just don't know. Everything seems to be working fine. V3 was asked if he had done any water temperature checks today. V3 stated, I have checked the water twice so far today- I have not documented it yet. V3 was asked for any maintenance requests or a maintenance log. V3 stated, I am not logging the maintenance stuff. I just get texts or notes and then I complete the work. I will start doing that now. On 11/15/23 at 2:15 PM, after assessing the facility water system, V22 (HVAC/Mechanical Contractor) stated, The issue seemed to be purely a mechanical issue. I balanced the system. It is very touchy, and we were getting it up to almost 120 degrees Fahrenheit. Surveyor asked V22 if the power outage over the weekend and the need to reset the breakers on Monday could have anything to do with the water getting too hot. Surveyor explained to V22 that the water temperatures measured 150 degrees Fahrenheit. V22 stated, Oh, that is laundry temperature. That is the pump. If there was a power outage and the pump was not running at all you would be getting pure hot water from the return water pump, or the hot water would be backed up into the pipes. If that were the case, the rooms at the furthest and highest points would be affected by the hot water. (Surveyor explained to V22 that the rooms affected were at the furthest and highest point from the boiler). V22 stated, Then the pump could be going out- it is not a bronze pump, and they can fail. It sounds like the return loop was the problem with the hot water just sitting there. The facility water temperature logs for August, September, October, and November 2023 show daily water temperatures taken in random rooms and areas throughout the facility. There are no documented temperatures outside the expected range of 100-110 degrees Fahrenheit. The log for November 13, 2023, shows temperatures between 99.8- and 105.2-degrees Fahrenheit. (The elevated temperatures found at 12:40 PM are not documented on the log). The log for November 14, 2023, shows only one documented temperature reading. (V3 stated he had checked the temperatures twice before 12:30 PM on 11/14/23). The undated facility policy (revised on 11/15/23 as part of abatement plan) states, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Hot water systems that service resident rooms, bathrooms, common areas and tub/shower areas shall be set to temperature of no more than 110 degrees Fahrenheit or 43.3 degrees Celsius or the maximum allowable temperature per state regulations. The Immediate Jeopardy that began on 11/13/23 was removed and on 11/15/23 when the facility took the following actions to remove the immediacy: The facility has taken immediate corrective action to assure no serious injury, harm, impairment, or death occurred or would occur due to the presence of hot water beyond the maximum temperature of 110 degrees Fahrenheit allowed in the facility. Upon the identification of the hot water temperatures at resident areas the facility took the following steps: *Notified nursing staff to prevent any resident from using the faucets unassisted. *Contractor from (Local Mechanical Company) identified, on 11/15/23, the problem as being an imbalance between the high flow and low flow mixing valves which, in a building of this size, tends to raise the temperature as the water goes through the return loop. The problem was fixed by recalibrating the high flow and low flow mixing valves and keep testing the water temperatures at the furthest point in the building to assure that the water temperatures are in a range between 100- and 110-degrees Fahrenheit at resident use areas. *Additional temperatures were taken throughout the building at faucets in sinks and shower areas after the identification and adjustment of the mixing valve issue. *Contacted Facility plumbing contractor on 11/14/23 to come to the facility and inspect and run additional calibrations. *Facility has reviewed and revised its policies and procedures on testing hot water, identifying issues and assuring the safety of residents while corrective actions were taken. *In-services have been and will continue to be held with all facility staff, including any new hires and temporary staff assigned to the facility. In-services have been conducted by the Administrator and/or his designee and have begun on 11/15/23 and are ongoing. Staff who were not present were in-service via telephone. All staff are in-service prior to the start of their next shift. In-services included the following: *A review of the requirement to maintain safe water temperatures throughout the resident areas of the facility. *A review of the facility policies and procedures, as revised, of steps to be taken if hot water temperatures are identified, which include, but are not exhaustive, of the following. alert all nursing staff, post signs at water use areas, notify maintenance, plumbing contractors, maintain safety of residents until all issues are resolved. *Going forward, daily water temperatures will be taken by maintenance and/or designee at 10 randomly selected faucets and a log is kept. Whenever a temperature exceeds the maximum allowed amount of 110 degrees Fahrenheit, the facility's revised policies and procedures will be followed. *Any trends of noncompliance will be addressed immediately and noted on the Quality Assurance Report. Any trends of noncompliance will be reported at the next QAPI meeting. Administrator is responsible for overall compliance. Administrator and /or designee will monitor logs to ensure overall compliance. 35119 B. On 11/13/23 at 12:26 PM, R39 was in bed with her lunch tray on the bedside table on the right side of R39's bed. R17 (R39's roommate) was on R39's left side and was feeding R39 her lunch. R17 was repeatedly feeding R39 bite after bite of food with no drink given in between bites. R17 stated She almost ate all of it. That's my buddy, I feed her a lot. R39 had a mouthful of food and was swallowing very slowly. On 11/14/23 at 8:40 AM, V8 (Certified Nursing Assistant/CNA) said R39 is on a pureed diet and needs someone to feed her, she tires out easily and eats slowly. On 11/15/23 at 9:07 AM, V14 (Director of Rehab/Speech Therapy) said she is seeing R39 for tolerance of her current diet. V14 said R39 is slow to initiate eating and has difficulty managing her utensils. V14 said R39 needs staff to feed her. V14 said CNAs and/or Nursing should be feeding residents with mechanically altered diet. V14 said it is not safe for residents to feed other residents. R39's Speech Therapy Progress Report and Updated Therapy Plan dated 9/12/23 shows R39 has diagnoses of Alzheimer's, dementia, dysphagia, and cognitive communication deficit and requires variable verbal/visual/tactile instructions due to slow responses and initiation at times and nursing is aware of patient's need for feeding assist. R39's Care Plan shows I have dx (diagnosis) of late onset Alzheimer's dementia. Monitor and document intake every meal, provide cues and supervision with all meals and fluids, Monitor, document, report and s/sx (signs and symptoms) of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth. refusing to eat, appears concerned at meals. Notify MD if Speech therapy screen indicated, Registered dietician to evaluate and make recommendations as indicated, Monitor and report to MD s/sx malnutrition: emaciation (cachexia), muscle wasting, significant weight loss of 3lb in 1 week, 5% in 1 month, 7.5% in 3 months, or 10% in 6 months.

Based on observation, interview and record review the facility failed to have ordered pressure reducing interventions in place to prevent R72's stage 2 sacral pressure wound from deteriorating to a stage 3. R72's pressure wound increased in size and depth and worsened in condition. This applies to 1 of 3 residents (R72) reviewed for pressure wounds in the sample of 22. The findings include: R72's Minimum Data Set Assessment of 9/24/23 shows that R72 was admitted to the facility on [DATE] with diagnoses including Renal Insufficiency, Neurogenic Bladder and Paraplegia. This same assessment shows that R72 had a stage 2 pressure ulcer (wound) present upon admission. On 11/14/23 at 8:45 AM R72 was lying in bed awake. R72 was alert and oriented. R72 stated that he gets up sometimes but really doesn't have any motivation to get out of bed. R72 stated that he walked into the hospital, and they had to wheel him out. He stated that he is unable to walk and usually just prefers to stay in bed. R72's Initial Wound assessment dated [DATE] shows that R72 had a stage 2 sacral pressure wound (a partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. Granulation tissue, slough and eschar are not present) measuring 1.0 x 1.0 x .01 cm. The wound is described as 100% pink or red non-granulating tissue with a scant amount of serous (yellow or transparent) drainage. The treatment is listed as Collagen and foam. On 11/16/23 at 2:30 PM, V11 (Licensed Practical Nurse/Wound Nurse) stated, Wound Rounds must have had a glitch because my assessments were not in there. I have these. V11 provided Surveyor with 2 handwritten wound assessments dated 9/28 and 10/4. Surveyor asked why the first assessment by (V12 Wound Nurse Practitioner) was not done until 10/10/23 and V11 stated, I did not think the wound needed to be seen by (V12) until then. R72's Handwritten Wound Assessment (Without pictures) dated 9/28/23 describes the sacral wound as unstageable (a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar), measuring 1.0 x 1.0 x 0.01 cm (declined from a stage 2). The treatment is listed as collagen and a bordered foam dressing. R72's Handwritten Wound Assessment (Without Pictures) dated 10/4/23 (16 days after admission) also shows the sacral wound as unstageable, measuring 1.0 x 1.0 x 0.01 cm. The same treatment was continued, collagen and bordered foam. R72's Initial Wound Assessment done by V12 and dated 10/10/23 shows that R72 has an unstageable sacral wound, present on admission. The assessment shows the wound as 1.8 x 1.4 x 0.1 cm, 90% slough (devitalized tissue) and 10% non-granulating red tissue. This assessment also states, The pressure ulcer is to be offloaded using low air loss mattress. On 11/14/23 at 10:09 AM V11 and V12 assessed R72's wound with Surveyor present. R72 was lying on a regular facility mattress, not a low air loss mattress. V11 stated, He had a low air loss mattress but we were having a problem with the pumps-so we had to order him a new one. It may be downstairs because we got a shipment in today. V11 was unsure how long R72 had been without the low air loss mattress. At 10:20 AM V12 stated, Every resident with a stage 3 should have a low air loss mattress, I noticed that today. I don't recall if he ever had one. R72's undated care plan shows that R72 has a stage 2 pressure ulcer to the coccyx. The interventions include Follow facility policies/protocols for the prevention/treatment of skin breakdown. R72's Physician's Order Sheet dated November 2023 shows an order dated 11/14/23 for a Low Air Loss Mattress. The facility policy entitled Prevention of Pressure Ulcers/Injuries dated July 2017 states, Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight and overall risk factors.

Based on interview and record review, the facility failed to test and record the wash and rinse temperatures of their high temperature dishwasher three times a day. This failure has the potential to affect all 68 residents residing in the facility. The findings include: The facility CMS 671 dated 11/13/23 shows there are 68 residents in the facility. During the initial tour of the kitchen on 11/13/23 at 9:33 AM, the facility's Dish Machine Log-High Temp was reviewed for November 2023. No wash or rinse temperatures were recorded under Supper on 11/10/23, 11/11/23, or 11/12/23. On 11/15/23 at 10:05 AM, V17 (Dietary Manager) said she checks the dishwasher temperatures in the morning when she first arrives and before dishes from each meal service are washed. V17 said she will run an empty load first before proceeding to wash dishes in order to verify the temperature is in the correct temperature range. The Dish Machine Log-High Temp dated November 2023 shows, Instructions: Record wash and rinse temperature, and provide initials, three times per day.

Based on observation, interview and record review facility failed to ensure sure staff doffed PPE (personal protective equipment) in a manner to prevent cross-contamination after caring for COVID-19 positive residents. The facility failed to ensure 5 residents (R51, R58, R2, R15, R7) on contact/droplet transmission-based precautions had the required isolation signage outside of their rooms. The facility failed to have an effective system in place to test staff and 5 residents (R68, R48, R61, R23, R60) for COVID-19 during a facility outbreak. The facility failed to ensure COVID negative residents were not exposed to 3 residents (R68, R4, R51) who were COVID positive. These failures resulted in a facility outbreak of COVID-19 which, as of 11/13/23, included twenty-nine positive residents and sixteen positive staff. These failures have the potential to affect all 68 residents residing in the facility. The findings include: The facility CMS-671 dated 11/13/23 shows there are 68 residents residing in the facility. 1. On 11/14/23 at 3:21 PM, V2 (Director of Nursing/DON/Infection Preventionist) said that on Friday, 11/3/23, three residents (R68, R48, and R61) started having a cough and lethargy. V2 said they tested the three residents on 11/3/23 and all three were COVID positive, thus beginning their COVID outbreak. V2 said the three residents were all friends who resided on the first floor. V2 said they did not test staff who cared for R68, R48, and R61 on 11/3/23. V2 said a definitive source was not identified through contact tracing for the COVID outbreak, but speculated the three residents got it from their church group the previous Sunday (10/29/23). V2 said she became ill over the weekend of 11/4/23 and 11/5/23 and tested positive for COVID on 11/6/23. V2 said the nurses tested all residents and staff on the first floor for COVID on 11/6/23. V2 said she told V28 (Assistant DON) to put up contact/droplet isolation signs on the doors of the residents being isolated for COVID-19 but was not in the facility to make sure it was done until Monday, 11/13/23. V2 said V1 (Administrator) who was her back-up during her absence, did not implement any COVID testing when she was out with COVID over the weekend of 11/4/23 or 11/5/23. On 11/16/23 at 8:28 AM, V2 said she could not remember testing staff or residents on 11/3/23, but all staff that worked on the first floor within the previous five days of identifying the COVID outbreak on 11/3/23 and all residents on the first floor were tested on [DATE]. V2 said she did not write out COVID tests on 11/3/23, she just checked the residents off on a printed roster. On 11/16/23 at 10:39 AM, V29 (Licensed Practical Nurse/LPN) said R23 and R60 both reside on the first floor. V29 said R23 was at an appointment on 11/3/23 and R60 was out on pass on 11/3/23, so she knows they were not tested on [DATE]. V29 said she only tested two staff members on 11/3/23. V29 said she does not have copies of the tests she performed; she had a resident census sheet she used to check mark. On 11/16/23 at 8:41 AM, V24 (Receptionist) said she always works at the reception desk on the first floor. V24 said she was tested for COVID on the Monday (11/6/23) after she returned to work from the weekend following the identification of the COVID positive residents. V24 said she was not tested for COVID on 11/3/23. On 11/16/23 at 8:57 AM, V15 (Registered Nurse/RN) said she worked on the first floor on 11/2/23 and was the nurse assigned to R68, R48, and R61. V15 said she was not tested for COVID on 11/3/23 and no one contacted her over the weekend. V15 said she came in Monday, 11/6/23, and tested herself for COVID. On 11/16/23 at 9:18 AM, V25 (Housekeeping Director) said he works in the facility Monday through Friday. V25 said he works all over the building and is everywhere helping his staff. V25 said he was not tested for COVID on 11/3/23 but was sick over the weekend (of 11/4/23 and 11/5/23) and that is why he came into the facility on Monday 11/6/23 and got tested for COVID, for which, he was positive. A document titled Second Floor (undated) was provided by the facility and shows what V2 said are the COVID-19 positive residents as of 11/13/23 on the first floor. It lists five residents. A document titled First Floor (undated) was provided by the facility and shows what V2 said are the COVID-19 positive residents as of 11/13/23 on the first floor. It lists 24 residents. A document with the handwritten title Employees (undated) was provided by the facility and shows what V2 said are the COVID-19 positive employees as of 11/13/23 in the facility. It lists 16 staff members. No proof of COVID-19 testing for residents or staff was provided by the facility for 11/3/23. The facility's Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus (COVID-19) Policy (last revised 6/16/23) shows a broad-based approach to an outbreak is preferred if all potential contacts cannot be identified with contact tracing. The facility's Interim COVID-19 Testing-Residents and Staff Policy provided by the facility (last revised 5/12/23) shows the facility should perform testing for all residents and health care providers identified as close contacts or on the affected unit(s) if using a broad-based approach. The above referenced Policy also shows under Documentation of Testing: Upon identification of a new COVID-19 case in the facility (i.e., outbreak), document the date the case was identified, the date that all other residents and staff are tested , the dates that staff and residents who tested negative are retested , and the results of all tests. 35119 2. On 11/13/23 at 11:15 AM, R4 stated Thursday (11/2/23) night my roommate (R68) got sick and was sent out to hospital. When he came back, he was Covid positive and put back in the room with me. They did move him over the weekend, but they should not have put him in the same room with me when he came back from the hospital. I was not tested until Monday and then I tested positive. On 11/16/23 at 08:52 AM, V23 (Licensed Practical Nurse) stated I worked the evening of 11/2/23 when R68 was admitted back from the hospital. He went back into his old room. He came really late that night. R68 was still in his room when I finished my shift in the morning. I spoke to V2 (Director of Nursing) and informed her he was admitted back Covid positive. I was not instructed to do anything. R4's Census List shows R4 is and has been in room YYY-B. R68's Census List shows R68 was in room YYY-A until 11/3/23 at 1:41 PM. R4's Minimum Data Set, dated dated dated [DATE] shows R4 is cognitively intact. R4's Progress Note dated 11/6/23 at 2:50 PM (Monday) shows R4 tested Covid-19 positive. R68's Progress Note dated 11/2/23 at 11:40 PM shows R68 returned from the hospital positive for Covid-19. The facility's Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus (COVID-19) Policy dated 6/14/23 shows Place a patient with suspected or confirmed Sars-Cov-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. 44688 3. On 11/13/23 at 10:01 AM, V19 (RN) came out of an isolation room that had signs on the door for contact/droplet precaution. She was donned in her isolation gown, gloves, and mask. She removed the gown and gloves on the outside of room door and took them down the hall. V19 did not wash her hands nor sanitize them. She threw the gown and gloves away in her trash on her medication cart. On 11/13/23 at 10:05 AM, V19 said I did not see a trash can inside the room, so I put it here. On 11/16/23 at 8:33 AM, V2 (Director of Nursing) DON said they should dispose of Personal Protective Equipment (PPE) at the door before they come out the room. It is an infection control issue. 11/16/23 at 9:16 AM, V1 (Administrator) said The PPE should be disposed of in the room just before they exit the rooms. That also is potential exposure to others if they touch someone. 22499 4. R51's Physician's Order Sheet dated November 2023 shows that R51 has a diagnosis of Dementia and Alzheimer's Disease. This same form shows that R51 was placed on contact/droplet isolation precautions (for COVID 19) on 11/10/23. On 11/13/23 at 12:09 PM R51 was seen ambulating down the hallway on the second floor. R51's mask was on but down around her chin. R51 was approached by several staff and assisted to pull her mask up but R51 became very agitated and aggressive and would immediately pull the mask back down. R51 was assisted back to her room by the staff, shown where her snacks were in the room and then the door was shut to try to keep R51 in the room. Within 2 minutes R51 was back at the doorway with the door open, then in the hallway and messing with the PPE on the cart outside of her room, then standing in the doorway of the room across the hall from hers. On 11/13/23 at 12:16 PM V11 (LPN/Wound Nurse) stated to Surveyor, We can't restrain her, and she just doesn't understand. Do you have any suggestions for what we can do with her? On 11/13/23 at 1:00 PM R51 was up and out of her room again. Again, messing with the PPE on the cart outside her room. R1 continued walking up and down the hall, stopping to touch carts, other resident wheelchairs and approached 2 Surveyors, attempting to touch the safety glasses of one of the Surveyors. R51 was again approached by staff multiple times and asked to pull her mask up, but then R51 pulls it down again, gets agitated and pulls away from staff. The facility policy entitled Infection Prevention and Control Interim Guideline for Suspected or confirmed Coronavirus dated 6/14/23 states, Place a patient with suspected or confirmed SARS-CoV2 infection in a single- person room. The door should be kept closed (if safe to do so). 5. On 11/13/23 the facility reported that there were 5 residents positive for COVID residing on the second floor of the facility. The residents included R51, R58, R2, R15 and R7. On 11/13/23 at 9:00 AM, all 5 residents' rooms on the second floor had signs posted showing Contact Isolation. There were no Droplet Isolation signs observed on the doors. Around 10:00 AM V2 (Director of Nursing) was observed posting Droplet Isolation signs on the doors. V2 stated, I wasn't here last week so I am just getting the signs up now. All 5 residents on the second floor came up positive for COVID on 11/9/23. The facility policy entitled Infection Prevention and Control Interim Guideline for Suspected or Confirmed Coronavirus dated 6/14/23 states, Post signs on the door or wall outside of the resident room to clearly describe the type of precaution needed and required PPE.

Based on observation, interview and record review the facility failed to ensure a resident had a care plan to address pain for 1 of 22 residents (R44) reviewed for the development and implementation of a comprehensive care plan in the sample of 22. The findings include: R44's face sheet printed on 11/15/23 showed she was admitted on [DATE] with diagnoses to include, but not limited to, left knee osteoarthritis, cellulitis of left lower limb, pain in right shoulder, and pain in left shoulder. R44's physicians order sheet printed on 11/15/23 showed Acetaminophen-Codeine 300-30mg (milligrams) one tab by mouth two times a day for osteoarthritis, diclofenac sodium external gel 1% apply to skin topically as needed for pain control 4 times a day as needed, Lidocaine pain relieving patch 4% apply to skin topically in the morning for pain control and remove per schedule. R44's Minimum Data Set (MDS) dated [DATE] showed R44 as moderately cognitive impaired. Bed mobility requires limited assistance of one staff, transfers one assist of staff and toileting requires limited assistance with one staff assist. R44 receives scheduled pain medication. R44's Pain assessment dated [DATE] showed R44's pain score as four (4). R44's Care Plan printed on 11/15/23 showed no pain care plan documented. On 11/15/23 at 9:23 AM, R44 said I am doing ok. My pain is always there but they just gave me something. It is there constantly. On 11/15/23 at 9:46 AM, V15 (Registered Nurse) said She (R44) always says pain, pain. But if someone is with her and stays and talks with her, she is fine, there is no pain. She does have a lidocaine patch and she gets Tylenol with codeine twice daily. On 11/15/23 at 10:26 AM, V27 (Social Service Director) said I looked but I didn't see one (pain care plan). I don't do the pain care plan that would be V2 (Director of Nursing/DON). On 11/15/23 at 10:32 AM, V2 (DON) said Yes I do the care plans for nursing. I don't see one for pain (for R44). The facility's policy titled Care Plans, Comprehensive Person-Centered showed 8. the comprehensive, person-centered care plan will: b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review the facility failed to remove a resident's facial hair and failed to provide set up assistance for meals for 2 of 22 residents (R17, R70) reviewed for activities of daily living in the sample of 22. The findings include: 1. On 11/13/23 at 9:52 AM, R17 was sitting up in her wheelchair. R17 had a mustache and facial hair on her chin and neck. R17 stated I don't like this (and rubbed her chin), and I don't like a mustache either. On 11/14/23 at 8:40 AM, R17 was in her room sitting at the bedside, eating breakfast. R17's facial hair and mustache remained. V8 (Certified Nursing Assistant/CNA) said R17 needs help with activities of daily living. V8 said R17 is supposed to get her face shaved during showers. V8 looked at R17 and stated They must not have done it with her shower over the weekend. R17 doesn't like the hair on her face. I will get the electric razor and take care of it. R17's Minimum Data Set, dated dated dated [DATE] shows R17 needs extensive assist of one person for personal hygiene. The undated facility's Shaving Male and Female Residents Policy shows Purpose: To provide cleanliness, comfort, and improved morale. Female residents will be assessed weekly, and assistance provided in accordance with the resident's preference. 44688 2. R70's Face sheet printed on 11/15/23 showed he was admitted on [DATE] with diagnoses to include, but not limited to, fall on same level from slipping, tripping, and stumbling, essential hypertension, osteoarthritis, and gout. R70's Minimum Data Set (MDS) dated [DATE] shows R70 has moderate cognitive impairment. Eating with supervision once the food is placed before the resident. R70's Occupational Therapy notes dated 11/14/23-12/24/23 showed eating: set up or clean up assistance. On 11/14/23 at 9:42 AM, R70 said, I need help with eating I can't raise my arms all the way, I can't open my milk and I drop my food. On 11/14/23 at 12:48 PM, R70 was sitting on the side of his bed at his bed side table attempting to eat his meal. R70 used his right hand to cut sliced potatoes, used a spoon for sliced green beans and the mechanical soft meat. Some green beans fell off the plate and onto the tray. Pieces of potatoes were noted on tray. A blue bowl with an unopened lid remained on the table with a food item inside of the bowl. On 11/14/23 at 12:49 PM, R70 said it's too late now I need someone to help me before I start. On 11/14/23 at 12:59 PM, V10 (CNA) said she asked (R70) if he needed help and he said no. He said he was having difficulty, but he said no. On 11/15/23 at 11:29 AM, V18 (Occupational Therapist/OT) said she is familiar with (R70). We are working with him on both upper extremities. Both shoulders limited with ROM (range of motion), weakness bilateral (both sides). He complains occasionally of pain to his right arm. He has an old fracture to his right hand and the pain is consistent with that. He needs help opening containers and removing the lids from the bowls. On 11/15/23 at 11:40 AM, V21 (CNA) said Yes, I am familiar with (R70). I am taking care of him today. I did pass his trays for him today. If someone does not help him with the lids it could be difficult for him to start eating. He can't get the containers open. The facility's policy titled Assistance with Meals shows residents shall receive assistance with meals in a manner that meets the individual needs of each resident.

Based on observation, interview, and record review, the facility failed to provide the necessary supervision to a resident to prevent a fall that resulted in a serious injury. This failure resulted in R1 sustaining a leg fracture because of the fall, that required urgent surgery upon admission to the hospital on July 11, 2023. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 9. The findings include: R1's EMR (Electronic Health Record) showed R1 was readmitted to the facility on [DATE], and discharged to the local hospital on July 11, 2023. R1 had multiple diagnoses that including Dementia with psychotic disturbance, glaucoma, hypertension, atherosclerotic heart disease, repeated falls, and cognitive communication deficit. R1's most recent fall risk assessment dated [DATE], showed R1 was at high risk for falls. R1's MDS (Minimum Data Set) dated April 18, 2023, showed R1 had severe cognitive impairment, required extensive assistance with bed mobility and transfer, did not walk, was dependent on staff for locomotion. Also required extensive assistance for dressing, personal hygiene and eating. R1's care plan had a fall intervention dated May 1, 2022, that stated Remain in a room near the nurse's station for visual checks. R1 sustained an unwitnessed fall on July 9, 2023, at 6:30 PM, as documented in R1's EMR (Electronic Medical Record). On July 17, 2023, at 4:23 PM, V10 (CNA-Certified Nursing Assistant) stated R1 was noted on the floor, face on the floor, on her knees, in front of her wheelchair on July 9, 2023, at approximately 6:30 PM. On July 20, 2023, at 1:14 PM, V10 (CNA) stated she was passing dinner trays and there was no staff at the nurse's station, when she saw R1 had a fall on July 9, 2023. V10 stated she called for V12 (LPN-Licensed Practical Nurse) who was passing medications in the hall, to assist with R1 after the fall. V10 stated V12 came, and they assisted R1 to a sitting position with R1's legs in front of her and then assisted R1 back into her wheelchair by lifting R1 up. V10 stated that process took about one to two minutes. V10 also stated after R1 was seated in the wheelchair, V10 left the nurses station to return to passing dinner trays and V12 texted V7 (LPN) to let her know that her assigned resident, R1 had a fall because V7 was not in the facility at the time. V7 (LPN) stated on July 17, 2023, at 2:15 PM, that she was R1's assigned nurse on July 9, 2023, on the evening shift and was not in the facility at the time of R1's fall. V7 stated R1 is usually sitting in her wheelchair behind the nurse's station so staff can keep an eye on her. V7 stated around 6:00 PM on July 9, 2023, V7 left the facility to go on break and as she exited the building her coworker V12 (LPN) was already outside the building on break. V8 (CNA) stated on July 17, 2023, at 3:21 PM, that V8 worked the evening shift on July 9, 2023, and saw R1 sitting in her wheelchair, at the nurse's station and noticed bruising on R1's face around 6:30 PM. V8 stated V12 (LPN) told her that R1 just had a fall. V8 also stated she was unaware of the time when V7 went on break and was not asked to supervise R1 during that shift. V11 (CNA) stated on July 17, 2023, at 4:09 PM, that she was assigned to care for R1 on July 9, 2023, during the evening shift. V11 stated around 7:30 PM she was putting R1 to bed and noticed a bruise on R1's face. V11 stated she put R1 back into the wheelchair and took her to the nurse's station to show V7 (LPN) the bruise on R1's face. V11 (CNA) stated V10 (CNA) saw V11 taking R1 to the nurse's station and told V11 that R1 had fallen earlier. V11 further stated she was unaware when V7 (LPN) left the building to go on break and was not asked to watch R1 during that shift. V11 (CNA) had stated to V2, (DON), who provided a written statement on July 19, 2023, that on July 9, 2023, evening shift, V11 had fed R1 dinner between 5:15-5:30 PM at the nurse's station and then went to assist other residents with the dinner meal, leaving R1 in the nurse's station. On July 20, 2023, at 9:15 AM, V35 (CNA) stated she works in the facility full time and knows R1 well. V35 stated staff bring R1 to the nurse's station so all staff can keep an eye on her. V35 demonstrated the usual position of R1 when sitting at the nurse's station. R1 sits in her wheelchair and likes to rock back and forth. V35 stated R1 sits behind the nurse's station, at the counter, and puts both knees flexed, up against the counter, and moves back and forth in a rocking motion. V35 further stated R1 sits next to staff at the counter while staff chart on the computer. V10 (CNA) stated on July 20, 2023, at 1:14 PM that at the time of the fall on July 9, 2023, R1 was sitting away from the counter on the left side of the nurse's station, with no counter in front of her. The wheelchair was upright, and R1 was face down on the floor in a kneeling position on the floor. On July 20, 2023, at 9:30 AM, V34 (LPN) stated she has worked at the facility for eight years and has worked with R1 since her admission to the facility and knows R1 well. V34 stated R1 requires a lot of attention and somebody must keep an eye on her at all times. V34 further stated that R1's routine includes if she is awake, staff keep her at the nurse's station and R1 sits behind the counter with staff while in her wheelchair. V34 also stated that nursing staff know staff are not to take their breaks during resident mealtimes. Staff break times are assigned to occur either before or after resident mealtimes. V34 also stated that nurses cover for each other during staff breaks and don't leave the unit at the same time for breaks. On July 19, 2023, at 4:51 PM, V21 (R1's Physician) stated he relies on the facility nurses to inform him regarding a resident's injury as the nurses are his eyes and ears. V21 stated he did not receive any information regarding injury to R1 until July 11, 2023, at 3:30 AM, via text and he ordered an X-ray of the left knee due to report of the knee swelling. V21 also stated had he been told that R1 had an unwitnessed fall from her wheelchair onto her face that resulted in facial bruising on July 9, 2023, V21 would have ordered to send R1 to the hospital immediately. V21 also stated the cause of the fracture was most definitely the fall on July 9, 2023. R1's hospital record progress note dated July 11, 2023, by V36 (Orthopedic Surgeon) showed R1 had an open left distal femur fracture that likely occurred July 9, 2023, two days prior. V36 recommended urgent I&D (Incision and Drainage) of open fracture site in OR (Operating Room) with application of knee spanning external fixator. During multiple interviews, between July 17 and July 20, 2023, at various times, staff who worked the evening shift on July 9, 2023, V7(LPN), V10 (CNA), V11(CNA) and V8 (CNA) each stated R1 was at risk for falls and was kept at the nurse's station for visual monitoring. During additional staff interviews, between July 17 and July 20, 2023, at various times, V2 (DON), V35 (CNA), V34 (LPN), V33 (LPN), V9(LPN) and V6 (RN) each stated R1 was at risk for falls and R1 was often positioned behind the nurse's station to provide visual monitoring. The Facility policy Fall and Fall Risk, managing, dated March 2018, showed under the section, Resident-Centered Approaches to Managing Falls and Fall Risk, 1. The staff will implement a resident centered fall prevention plan to reduce the specific risk factor for each resident at risk.

Based on interview and record review, the facility failed to provide and document post (after) fall nursing assessments for a resident who sustained an unwitnessed fall with injury in accordance with their policy. This failure resulted in a delay in obtaining medical treatment for a resident with a displaced fracture of the leg bone and contusion of the forehead and eye orbit. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 9. The findings include: R1's EMR (Electronic Health Record) showed R1 was readmitted to the facility on [DATE], and discharged to the local Hospital on July 11, 2023. R1 had multiple diagnoses including Dementia with psychotic disturbance, glaucoma, hypertension, atherosclerotic heart disease, repeated falls, and cognitive communication deficit. R1's most recent fall risk assessment dated [DATE], showed R1 was at high risk for falls. R1's MDS (Minimum Data Set) dated April 18, 2023, showed R1 had severe cognitive impairment, required extensive assistance with bed mobility and transfer, did not walk, and was dependent on staff for locomotion. R1 also required extensive assistance of 1 for dressing, personal hygiene and eating. R1 was always incontinent of bowel and bladder. R1's actual fall care plan-initiated December 6, 2022, with goal revised on June 2023, showed interventions included to Monitor/document/report PRN (as needed) x 72 hours to MD for s/sx. (Signs and symptoms) pain, bruises, changes in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation. R1's EMR showed on July 9, 2023, at 6:30 PM, R1 was found lying on the floor with abrasions to the forehead, under eye and right knee. There was no documentation of any range of motion assessment for R1, or an evaluation for possible injuries to the head, neck, spine, and extremities. R1's EMR showed there were no nursing assessment progress notes on July 9, 2023-night shift (11:00 PM-7:30 AM) and July 10, 2023-day shift (7:00 AM-3:30 PM). R1's EMR showed no documentation regarding a range of motion assessment for any extremity at the time of the fall on July 9, 2023, until transfer to the hospital on July 11, 2023. R1's vital signs record showed vital signs were not documented on July 10, day, evening and night shift or July 11, 2023, day shift. On July 20, 2023, at 9:30 AM, V34 (LPN-Licensed Practical Nurse) stated that she worked on July 10, 2023, day shift and was assigned to R1. V34 stated she did not receive a shift report from V7 (LPN) when coming on duty. V34 stated throughout her shift she was not aware of R1's fall the previous evening and did not do a post fall assessment or neuro checklist on R1 during her shift. On July 18, 2023, at 3:36 PM, V33 (LPN) stated she worked on July 10, 2023, on the evening shift (3:00 PM to 11:30 PM) and was assigned to R1. V33 stated she did not receive a shift report from V34 (LPN) when she came on duty and did not know of R1's fall from the previous day. V33 stated R1 slept in her bed until around 6:30 PM when V33 woke R1 up to take her medication. V33 then noticed R1 had a black eye and bruising to the right side of her face and V33 checked R1's EMR and discovered that R1 had fallen the day before. V33 stated she did not do neuro checklist form in EMR for her shift. V33 also stated she was unsure of what to do for follow up after a resident had a fall. V33 stated she made a late entry progress note for the shift (July 10, 2023, evening shift) on July 12, 2023, when the Supervisor told her how to do it. On July 17, 2023, at 2:31 PM, V6 (RN-Registered Nurse) stated she became aware that R1 had a femur fracture on July 11, 2023, at 9:00 AM when she took the radiology results from the fax machine. V6 further stated R1's left knee was swollen. On July 17, 2023, at 10:33 AM, V9 (LPN) stated she was with V2 (DON-Director of Nursing) on July 11, 2023, in R1's room prior to R1's transfer to the hospital. V9 stated R1's left knee was really swollen and her leg was in a flexed positioned, and her leg looked as if the bone was out of place. V9 also noted there was a break in the skin on the outside of the left knee and it looked as if the bone was protruding through the skin. On July 18, 2023, at 11:18 AM, V2 (DON) stated, on July 11, 2023, V9 (LPN) informed me regarding the small hole on the side of left knee that was described as a bone protruding through the skin. V2 stated at the time of the fall there was an abrasion to the knee, and it is the left knee, the same leg as the one that was fractured. R1's Emergency Department Physician Report dated July 11, 2023, showed R1 had facial hematoma on the right forehead and right upper eyelid. R1 also had left knee deformity with one centimeter skin opening with bone protrusion. R1's hospital record progress note dated July 11, 2023, by V36 (Physician, orthopedic surgeon) showed R1 had an open left distal femur fracture that likely occurred July 9, 2023, two days prior. V36 recommended urgent I&D (incision and drainage) of open fracture site in OR (operating room) with application of knee spanning external fixator. On July 19, 2023, at 4:51 PM, V21 (R1's Physician) stated he relies on the facility nurses to inform him regarding a resident's injury as the nurses are his eyes and ears. V21 further stated he expects nurses to perform neuro checks and nursing assessments for residents who experience an unwitnessed fall or hit their head. V21 stated he did not receive any information regarding injury to R1 until July 11, 2023, at 3:30 AM, via text and he ordered an X-ray of the left knee due to report of the knee swelling. V21 also stated had he been told that R1 had an unwitnessed fall from her wheelchair onto her face that resulted in facial bruising on July 9, 2023, V21 would have ordered to send R1 to the hospital immediately. On July 19, 2023, at 10:38 AM, V2 (DON) stated the expectation following a fall with injury is for documentation of assessment of the resident for 72 hours. When asked if staff is expected to document the assessment each shift V2 stated I hope so. The facility's document titled Falls:, undated, indicated .9. Follow up 72 Hours Post Fall with Neuro checks, Vitals, changes in ROM (range of motion) or LOC (level of consciousness). The facility's policy titled Falls -Clinical Protocol dated March 2018 indicated in paragraph 2, . the nurse shall assess and document /report the following: a. vital signs, b. Recent injury especially fracture or head injury, c. Musculoskeletal function, observing for changes in normal range of motion, weight bearing, etc., d. Change in cognition or level of consciousness e. neurological status f. pain The facility's policy titled Neurological assessment dated [DATE], indicated under general guidelines section that neurological assessments are to be completed 1. b. following an unwitnessed fall, and 2. When assessing neurological status always include frequent vital signs. Particular attention should be paid to widening pulse pressure (the difference between systolic and diastolic pressures) This may be indicative of increasing intracranial pressure (ICP).

Based on observation, interview and record review, the facility failed to provide necessary care and services to promote healing, prevent infection and prevent facility acquired pressure ulcers from deterioration. This applies to 4 of 4 residents (R1 through R4) reviewed for pressure ulcers. This failure resulted in R1 developing a facility acquired pressure ulcer from a stage 2 that had worsened to stage 4. R1 was sent to hospital and was identified with infection of the coccyx pressure ulcer and pain on the site. R1 had undergone two surgical debridements for the pressure ulcer. The findings include: 1. The POS (Physician order [REDACTED]. The admission/discharge log showed that R1 was originally admitted to the facility on [DATE]. The log showed that R1 had multiple admissions to the hospital. The reason for hospital visits were mostly related to R1's urinary tract infection and kidney stones. The most recent hospitalization was on August 27, 2017 due to urinary tract infections [MEDICAL CONDITION]. R1 was readmitted back to the facility on [DATE]. The nurse's progress notes showed that R1 had no pressure ulcer when she was readmitted . However, the nurse's progress notes showed the following documentation regarding details of R1's developing pressure ulcer: -September 30, 2017 showed that R1 had acquired a stage 2 pressure ulcer on the coccyx measuring 1 cm. in length x 1 cm. in width in length. The notes also showed that Zinc Oxide was applied and covered with foam dressing. -October 1, 2017 showed that Z1 (Attending Physician) and Z2 (R1's family member) were notified regarding R1's pressure ulcer on the coccyx. The notes also showed a wound consultation was requested. - October 3, 2017 showed that R1's pressure ulcer had increased in size to 3.2 cm in length; 2.3 cm in width; ;40 % slough , small exudate. The treatment order was changed to [MEDICATION NAME] dressing by E3 (Licensed Practical Nurse/wound treatment nurse) and informed Z1 via fax. On October 3, 2017, Z1 responded via fax for an order of Wound Care. - October 5, 2017, there was fax documentation from Z1 for order of Wound Care and frequent repositioning. The weekly pressure ulcer assessment showed the deterioration of R1's pressure ulcer: -October 3, 2017, stage 2 pressure ulcer on the coccyx measured 3.20 cm. in length x 2.30 cm in width x 0.10 cm in depth. -October 9, 2017, pressure ulcer measurement was 3.50 in length x 3 cm in width x 0.20 cm in depth, exudate on dressing. -October 17, 2017, measurement was 3.50 cm in length x 3.30 cm in width x 0.20 cm. in depth, exudate on dressing -October 23, 2017, measurement was 4.50 cm. in length x 3.30 cm in width x 2.0 in depth. The assessment showed that the pressure ulcer was worse and from a stage 2, now was unstageable. The above pressure ulcer assessments showed that R1's pressure ulcer had worsened in a matter of 22 days from 1cm x1 cm stage 2 (September 30, 2017) to 4.50 x 3.30 x 2.0 unstageable ulcer. The progress notes from October 1, 2017 to October 25, 2017 showed no documentation that R1 was seen by the wound care physician specialist. The progress notes entered by E5 (Registered Nurse) on October 1, 2017 for a wound consultation was not followed. Z1's order that was sent to facility via fax on October 3 and 5, 2017 for Wound Care was not followed nor the facility had verified with Z1 what encompasses Wound Care. On October 31, 2017 at 2:00 P.M., E5 stated that on October 1, 2017, she updated Z1 regarding R1's pressure ulcer and there was a request for wound consultation. E5 further stated that wound consultation includes wound physician referral, nutritionist and wound care team to ensure correct treatment. E5 also stated that she did not inform the wound physician specialist and the nutritionist. E5 added that she instructed her CNA (Certified Nurse Assistant) for R1 to be turned and repositioned every 4 hours, as this is the standard to offload pressure from pressure points. On October 31, 2017 at 10:30 A.M., E1 (Administrator) stated that facility did not make a referral to the wound care physician specialist. E1 also added that wound care order should have been clarified with Z1. E1 further stated that wound care physician specialist should have been made aware to determine correct treatment. E1 further stated that facility's practice was to turn and reposition residents every 2 hours at a minimum to offload pressure. On October 31, 2017, E3 (Licensed practical Nurse) stated that R1 had been administered with enema from 4 times a day and was reduced to 2-3 times a day due to gastric problem. E3 also added that R1 was incontinent of stool and that the stool consistency was liquid like urine. As E3 added, incontinence care was provided. However, since R1 was incontinent, R1 was already wet with urine and stool by the time care was provided. E3 further stated that she did not verify with Z1 what the Wound Care order was. E3 also stated that the wound care physician was not notified until the 24th of October 2017. R1 was not seen by the wound care physician specialist since R1 was sent to the hospital on October 25, 2017 due to vomiting, pain on the buttocks area and chills. On October 31, 2017 at 1:40 P.M., E4 (Licensed Practical Nurse/Wound Treatment Nurse) stated that R1's pressure ulcer had deteriorated too fast from September 30, 2017 to October 3, 2017 based on the size measurement. E4 also stated that the pressure ulcer became unstageable on October 24, 2017 and that was when a referral was made to wound care physician specialist. However, R1 was not seen by the wound care physician specialist since R1 was sent out to the hospital on October 25, 2017 due to vomiting. The progress notes dated October 25, 2017 showed that R1 was sent to the hospital due to emesis, pain on the buttocks area and chills. The hospital record showed that R1 was admitted [DATE]. R1 was referred for pressure ulcer consultation. The ED (Emergency Department) report dated October 25, 2017 showed that R1 was noted with a large wound noted to coccyx and sacral area. Patient's states 10/10 pain to site. Wound is deep, moderate amount of yellow drainage noted to site. The hospital's wound care progress note report dated October 26, 2017 showed that there was a strong foul odor coming from the wound. Wound has signs of infection Sacrum wound 5.5 cm. x 5.0 cm. x 2.5 cm, unstageable pressure injury, present on admission, with moderate amount of serous drainage with foul odor present Wound bed is moist, grey black necrotic tissue. Wound edges have 0.5 cm undermining of from 4 o'clock, and 3.0 cm. undermining from 1 o'clock to 3 o'clock. Periwound has 3 cm blanchable [DIAGNOSES REDACTED] and warmth . Recommendations: need to follow with (wound care physician specialist) for debridement on October 27, 2017 Reposition every 2 hours at minimum to reduce pressure on at risk areas and wounds . The hospital wound progress report showed that R1's pressure ulcer on the coccyx was debrided on October 27, 2017 and a second debridement was scheduled on October 31, 2017. The progress notes showed that R1 has a stage 4 pressure ulcer on the coccyx. The pressure ulcer culture result dated October 25, 2017 showed there was an infection. On October 31, 2017 at 2:30 P.M., Z1 stated that (R1's) pressure ulcer could have been avoided if aggressive measures were implemented such as frequent turning and repositioning to relieve pressure; timeliness of providing incontinence care to maintain (R1) clean and dry; and a timely follow up with wound care physician specialist to determine correct treatment and prevent worsening of the wound. Z1 further stated, that even though R1 has [DIAGNOSES REDACTED]. Z1 also stated that (R1) does not have osteo[DIAGNOSES REDACTED] based on the bone scan result (done October 26, 2017) and it should not affect the wound's deterioration. R1's current care plan provided by the facility showed no specific interventions such as turning and repositioning schedule, and the timeliness of incontinence care to ensure R1 was maintained clean and dry. The MDS (Minimum Data Set) dated September 15 and 22 of 2017 showed that R1 requires extensive assistance with 2 person assistance for bed mobility and transfer. The MDS also showed that R1 was incontinent of bowel and bladder elimination. 2. On October 30, 2017 at 12:15 P.M., 1:30 P.M., 3:20 P.M., R2 was lying in bed on a supine position. On October 30, 2017 at 12:20 P.M., E9 (Licensed Practical Nurse) provided pressure ulcer treatment to R2. E8 (Certified Nurse Assistants) assisted E9. E8 and E9 turned R2 to sides to expose the pressure ulcer for treatment. R2's incontinent adult brief was moderately soaked with urine. E9 has a newly acquired stage 2 pressure ulcer on the coccyx that was unbeknownst to staff. R2 has an existing stage 2 pressure ulcer on the left buttock. The stage 2 on the coccyx was exposed and had no dressing. E8 stated that she was not paying attention whether the stage 2 pressure ulcer on the coccyx was there when she provided incontinence care at 11: 30 A.M. The MDS dated [DATE] showed R2 requires extensive assistance from staff for bed mobility and transfer. 3. On October 30, 2017 at 12:45 P.M., 1:45 P.M., 3:55 P.M., R3 was lying in bed in a supine position. R3 was in same position during these observations. On October 30, 2017 at 1:45 P.M., E4 applied antibiotic ointment to R3's multiple stage 2 pressure ulcers on bilateral buttocks. E4 did not apply dressing to cover the multiple stage 2 pressure ulcers. E4 responded when asked how the pressure ulcers were protected from contaminants such as feces. E4 stated that staff just have to provide incontinence care. The current care plan provided by the facility October 30,2017 showed that R3 has to be turned and repositioned at least every 2 hours, more often as needed or requested. The care plan was not followed based on observations made. 4. On October 30, 2017 at 12:15 P.M., 1:30 P.M., 3:20 P.M., R4 was lying in bed in a supine position. R4 was in same position during these observations. The MDS dated [DATE] showed that R4 requires extensive to total assistance from staff for bed mobility and transfer. The current care plan provided by the facility dated August 03, 2017 showed that R4 is at risk for impaired skin integrity related to impaired mobility and incontinence associated with cerebral infarction and [MEDICAL CONDITION]. The facility's undated policy for pressure ulcer treatment and guidelines showed that residents be turned and repositioned every 2 hours for mobility. The policy was not followed based on observations made.

Based on interview and record review the facility failed to ensure all hospital discharge medication orders are followed and provided to residents. This failure resulted in R1 not receiving 8 of 16 medications for 3 weeks (from April 25, 2017 through May 15, 2017 - 21 days). These medications includes anticoagulant, antiarrhythmic and diuretic medications. On May 15, 2017 R1 developed severe congestion and shortness of breath and was admitted to hospital intensive care unit with [DIAGNOSES REDACTED]. This applies to 1 of 3 residents (R1) reviewed for medication administration in the sample of 6 residents. The findings include: R1's electronic clinical record showed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's hospital discharge medication list dated April 24, 2017 includes 3 pages (marked as page 1, 2 and 3) of medication orders that includes 16 scheduled medications and 4 medications as needed (prn). All of these medications were transcribed to the Physician order [REDACTED]. On April 25, 2017 R1's Physician order [REDACTED]. These medications are as follows: 1. [MEDICATION NAME] HCL 200 mg, give one tablet by mouth one time a day - for [MEDICAL CONDITION]. 2. Eliquis (Anticoagulant) 5 mg give one tablet per mouth Twice a Day - for stroke and [MEDICAL CONDITION]. 3. [MEDICATION NAME] (Diuretic) 20 mg one tablet Twice a Day for diastolic heart failure. 4. Atorvastatin Calcium 40 mg one tablet by mouth at bedtime for [MEDICAL CONDITION]. 5. [MEDICATION NAME] 500 mcg give one tablet for [MEDICAL CONDITION]. 6. [MEDICATION NAME] give one tablet Twice a Day for [MEDICAL CONDITION]. 7. Vitamin D3 unit one capsule every Saturday for Vitamin D deficiency and, 8. [MEDICATION NAME] Nebulization (2.5 mg/3 ml) 0.083% 3mg/ml inhale orally via nebulizer every 6 hours as needed for shortness of breath. On May 30, 2017 at 1:30 PM, the Administrative staff (E1 (Administrator), E2 (Director of Nursing) and E11 (Assistant Director of Nursing) stated they are aware of these medication errors and they investigated it. They explained that the admitting nurse copied from the active hospital medication list, not from the discharge medication list/instruction form. Then a nurse (E6) came in the next day (April 25, 2017) and discontinued some of R1's medications without consulting the Physician. There was no documentation found in R1's electronic clinical record or presented as to why these medications were discontinued or that the attending physician was notified. On May 31, 2017 at 12:20 PM, E6 (Nurse) stated, The Director of Nursing (E2) brought R1's chart to me (on April 25, 2017) and said we (Director of Nursing and Assistant Director of Nursing) were doing chart audit and realized the admitting nurse used the active medication list from the hospital, not from the discharge list. E2 told me two times to correct it. E2 gave me two pages of the hospital-discharged orders and the stuff (medications) that I didn't see I discontinued it. These medication errors were not found until Z2 (Nurse Practioner) reviewed R1's chart on May 15, 2017 (21 days after admission). On June 1, 2017 at 11:20 AM, E8 (Nurse) stated, R1 was very congested. I do not need to use a stethoscope. I can hear him from the hallway, he was gurgling so loud, so I asked the Nurse Practitioner (Z2) to come and evaluate him. On June 1, 2017 at 12:40 PM Z2 reviewed her progress notes and explained, On May 15, 2017 I was asked by the nurse (E8) to evaluate R1 due to increasing shortness of breath, congestion, probably pneumonia versus aspiration. That was my first consult to R1 so I reviewed his medical records from the hospital and found that some medications prescribed from the hospital were not carried over. These medications are important to be continued. R1 has a pacemaker, history of [MEDICAL CONDITION], swollen lower extremities, [MEDICAL CONDITION] at that day he was so congested. Not giving the medications could have triggered something so I re-ordered it. The [MEDICATION NAME] HCL (antiarrhythmic medication), the [MEDICATION NAME] (diuretic), and the Eliquis (anticoagulant) - these are all important and he needed those medications. I reported this error to the Director of Nursing. Z2 also stated, When I evaluated him he was very congested and his lower extremities were [MEDICAL CONDITION]/swollen. He was diagnosed with [REDACTED]. On June 1, 2017 at 3:02 PM via phone, Z3 (Attending Physician) stated, I never recall getting a call from any facility staff asking about these medications to be discontinued. My practice is to approve or follow all hospital discharge orders. In his case, R1 is very fragile and he is very high risk; discontinuing those medications could affect him adversely. On June 1, 2017 at 11:30 AM, the facility Admission Director presented hospital history and physical and emergency record and stated, R1 is currently in the hospital Intensive care unit, comatose and has [DIAGNOSES REDACTED].

Based on observations, record reviews and interviews the facility failed to ensure that 2 out of 4 residents (R11 and R6) reviewed for falls, in a total sample of 15, were transferred appropriately and safely with the use of a transferring device. This failure resulted in a fall incident for R11 on 9/9/11. R11 sustained a fractured right ankle that required hospitalization . Findings include: 1. R11 has multiple [DIAGNOSES REDACTED]. On 11/2/11 at 12:08 PM, R11 was inside the first floor small dining room, waiting for lunch to be served. R11 was alert, verbally responsive and was able to respond appropriately to questions. R11 denied any pain or discomfort during this observation. R11's quarterly MDS (Minimum Data Set) dated June 22, 2011 indicated that R11 has no problem with temporal orientation and recall. The MDS indicated the following information under Section G. Functional Status: - Transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position (excludes to/from bath/toilet), scored - 3-2 (extensive assistance x one person physical assist), - Toilet use (how resident uses the toilet room, commode, bedpan or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; adjusts clothes), scored 3 - 2 (extensive assistance x one person physical assist), - walk in room (how resident walks between locations in his/her room), scored - 2 - 2 (limited assistance x one person physical assist). R11's records indicated history of a fall on 6/24/11, when the resident did a self transfer from bed to the wheelchair without calling for help. Further review of R11's records reflects an investigation report dated 9/9/11 indicating, "Incident occurred on 9-9-11 at 6:30 AM. resident was in the bathroom in her wheelchair and was going to transfer from wheelchair to toilet seat. CNA was with her. When resident stood up and took a step, her knees buckle down and she fell on her knees (possibly twisting her ankle at this point). CNA was noted standing behind the wheelchair by Nurse who came in to give medications." "It was noted during the investigation that CNA had inappropriate transfer for the resident. She should have used a gait belt and should have situated herself next (on the side) to the resident and not standing behind the wheelchair without using a gait belt during the transfer." The same investigation report reflects that R11 complained of pain on the right foot, after the fall incident. R11's physician ordered an x-ray of the right foot and ankle, which revealed a fracture to the right ankle. R11 was sent to the hospital for evaluation and treatment on 9/10/11 and came back to the facility on [DATE] with a short cast (from below knee to toes) on the right lower leg. During a meeting with the facility on 11/3/11 at 10:00 AM, E2 (Director of Nursing) stated that due to R11's history of fall on 6/24/11, the resident is considered at risk for fall. E2 indicated that it is best practice for the staff to use a gait belt to assist residents with ambulation and transfers, for those requiring limited and extensive assistance. Per E2, the CNA (E6) should have used a gait/transfer belt to transfer R11 on 9/9/11. On 11/3/11 at 11:45 AM, E6 (CNA/ Certified Nursing Assistant) stated that on 9/9/11 at around 6:30 AM, R11 was rushing to use the toilet, so she (E6) attempted to assist R11 during ambulation/transfer from the wheelchair to the toilet without the use of the gait/transfer belt. E6 stated that she was holding R11's left arm and left back side while R11 was walking towards the toilet. Per E6 during this process, R11's knees buckled, but R11 was able to continue walking. According to E6, the second time R11's knees buckled was the time when the resident fell on the floor. Per E6, R11's legs were in a crossed position when she fell on the floor and that R11 was sitting on her crossed legs on the floor. E6 stated that R11 was assessed by the nurse after the fall, but did not indicate any pain or discomfort. R11 was lifted manually from the floor after the fall and was placed back on her wheelchair. According to E6, R11 complained of foot pain (does not remember which foot) on 9/9/11 after breakfast. During the same interview, E6 acknowledged that she received orientation prior to 9/9/11, to use a gait/transfer belt, every time a resident is transferred and/or assisted. E6 acknowledged that she should have used a gait/transfer belt on R11, during the transfer assistance on 9/9/11. Review of E6's file shows evidence that she ( E6) received training regarding the use of gait belt during transfers on 1/17/11 and 5/17/11. E6's gait/transfer belt check- off sheet dated 1/17/11 and 5/17/11 indicated that the gait/transfer belt is applied to a resident, "When manual assist is required for general supervision, possibly limited assistance or assisting residents who have not been screened for a lift." The same gait/transfer belt check-off sheet indicated that a gait/transfer belt will be used to: "Help a resident to get up/sit down, Help a resident up from the floor, Transfer between bed and wheelchair or wheelchair and toilet, Support when walking, Protect resident who are unstable when walking and Help a resident maneuver when using the bathroom." 2. R6's current physician's orders [REDACTED]. R6's ordered medications included Lorazepam, Fentanyl Patch, Ambien 5mg, and Seroquel. On 11/01/11 at or about 11:00am R6's bed and wheelchair had alarms attached to them. Her bed was in low position. R6 was sitting in a wheelchair. She was calm and not attempting to get out of the chair. R6 stated, " I can not walk without a walker. My legs and shoulders are always in pain. I need help to get out of the chair." R6's Nursing Note dated September 05,2011 documented R6 was found on the floor in the bathroom doorway... the Certified Nursing Assistant ( CNA ) was helping her, and when R6 turned around, the CNA was gone as R6 attempted to sit in her wheelchair. R6 was assessed as having no physical injury at the time of the incident. When R6 was asked about the incident on 11/01/11, she could not remember the details of the incident. During the facility investigation of the incident, it was documented that R6 stated that the CNA helped her off the toilet. R6 was washing her hands with her walker in front of her. When she turned to sit down she fell on the floor. The CNA stated she thought the resident was able to walk to the chair by her self. The Director of Nursing ( DON ) informed the "new " CNA that she can not leave residents who have mobility alarms in the bathroom by themselves, and R6 was a one person assist with all care. The Team Review of R6's fall incident on 09/05/11 recommended that the following interventions be implemented: " Instruct CNA's to use gait belt minimum assist while ambulating with rolling walker." The Facility Lift Program Skills Check-off Sheet/Transfer Belt documented that E5, CNA, completed these requirements on 04/08/11. The sheet documented," Gait/Transfer Belt: Applications: When manual assist is required for general supervision... Help a resident to get up/sit down, ... Transfers between bed and wheelchair, or wheelchair and toilet, support when walking, Protect resident who are unstable when walking, and Help a resident maneuver when using the bathroom." On 11/03/11 at 10:55am E2, the DON, was interviewed regarding R6's fall incident of 09/05/11. E2 stated, " E5 was a fairly new CNA. She should have looked in the Kardex to review R6's care needs. R6 was on fall precautions prior to the fall incident. E5 should not have left R6 alone, especially since R6 is a fall risk.