Every finding on record at Crystal Pines Rehab & HCC

Based on interview and record review the facility failed to ensure a resident was free from misappropriation of property for 1 of 3 residents (R1) reviewed for abuse in the sample of 3. This past non-compliance occurred from 5/11/26 to 6/10/26.The findings include: R1's admission records shows he was admitted to the facility on [DATE]. R1's quarterly resident assessment and care screening dated 4/23/26 documents he was cognitively intact. R1s progress notes for 5/22/26 document he expired in the facility.On 6/11/26 at 9:00 AM, V1 (Administrator) said he was informed by a staff member on 6/4/26 a local restaurant employee had informed him of a staff member possibly using a resident's credit card. He said V4 (R1's nephew) had called the restaurant inquiring about receipts he had found going through paperwork. On 6/11/26 at 10:30 AM, V4 (R1's nephew) said when he was going through R1's papers he found receipts from a local restaurant dated 5/11/26. One receipt had charges for $58 and included shrimp dinners and 4 beers. Which he found odd considering (R1) did not drink. Then later in the same day there was another receipt for more shrimp and more beer. V4 said he called the restaurant to see if they could identify who charged the meals. The staff said they knew who it was, she was a regular [NAME]. V4 said he did not know about any of the charges until after (R1) passed, so he was unable to verify any further details.On 6/11/26 at 10:20 AM, V5 (Cook) said he had received a call from an employee/family friend at a local restaurant about a resident family member inquiring about receipts and the use of a credit card. V5 said he immediately reported the incident to the administrator. On 6/11/26 V1 said after he received the reported allegation, he spoke with the manager at the restaurant and learned R1's credit card had been used to purchase food. They identified V3 as the employee using the card. V1 said V3 said R1 had authorized her to use the credit card to get him some food and something for herself. V1 said this is something the facility does not allow. We can assist residents, but staff are not to perform financial transactions. V3 admitted to buying food for herself and also paying for ride share [NAME].On 6/11/26 calls and messages to V3 were not returned. In a written and signed statement, V3 reported R1 wanted food from the restaurant and let her use his card to purchase food. She bought food for herself and couple drinks and bought him some shrimp. She took the food to R1 the next day and paid him back the money. She also used the card to pay for ride shares.The 5/11/26 receipts show a purchase at 2:10 PM for $56.66 for 4 beers and 2 shrimp dinner orders. The second receipt for the same day at 5:15 PM was $30.00 for 1 beer and 2 orders of shrimp. Each transaction shows the credit card numbers were keyed in by the restaurant employee, and the order was under the name of V3. The facility's 6/9/26 final incident report documents the allegation of misappropriation of resident property was substantiated. V3 admitted to utilizing the residents credit card to make purchases for personal use in addition to purchases made for the resident.The facility November 2025 policy for Abuse, prevention and prohibition states that each resident has the right to be free from abuse. The facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The facility also prohibits misappropriation of resident property. Misappropriation of Resident Property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.Prior to the survey date of 6/11/26, the facility had taken the following action to correct the noncompliance:1. On 6/4/26 the all-facility staff were in-serviced on abuse and the facility Abuse, Prevention and Prohibition Policy- with a specific focus on Misappropriation of Funds (including misappropriation of resident funds). Reviewed the policy regarding accepting monetary gifts from residents and/or resident representatives and the policy regarding assisting residents from procuring items.2. On 6/8/26 the Administrator was in-serviced by the Regional Nurse regarding abuse and neglect and ethics.3. On 6/4/26 Interviews were conducted with other resident to determine if they had any items/monies missing. The results of the interviews revealed that no residents were missing money.4. V3's employment was suspended on 6/4/26 and terminated on 6/10/26. 5. The QAA committee reviewed the incident to ensure that all corrective measures will be implemented.

Based on interview and record review the facility failed to ensure an enteral feeding was administered as ordered 1 of 3 residents (R1) reviewed for enteral feedings in the sample of 3. This failure resulted in R1's admission to the acute care hospital for treatment of aspiration pneumonia.The findings include:R1's face sheet showed she was admitted to the facility 9/24/2020 with diagnoses to include hypokalemia, dysphagia, gastrostomy status, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, major depressive disorder, and anxiety disorder. R1's 6/26/25 facility assessment showed she had severe cognitive impairment, was dependent on staff for all cares, and had a feeding tube.R1's July 2025 Physician Order Sheet showed an order started 4/18/25, Enteral Feed Order: in the evening. Administer Novasource via PEG-tube at 60 cc/hr. On at 6:00 PM off at 6:00 AM. Total volume to be infused 720cc in 24 hours. May turn off for short periods of time for care and services. Verify total volume infused prior to turning off.R1's Care Plan initiated 11/29/23 showed, [R1] requires Enteral Feeding via PEG tube. The resident will be free of aspiration through the review date (revised 8/20/25) . The resident id dependent with tube feeding and water flushes. See MD (physician) orders for current feeding orders.R1's 7/29/25 Physician Note entered by V13 (R1's Physician/Facility Medical Director) showed, Date of Service: 7/29/25; Visit Type: Acute. Chief Complaint: I was requested to see the patient for being given bolus feeding accidentally last night. History of Present Illnesses. She has been on continuous tube feeding, she was given bolus feeding accidentally last night. She seems to have mild congestion indicating possible aspiration. She was given bolus tube feeding early this morning and last night. She did not show any vomiting. She seems congested with some rales. Will resume tube feeding when she's stable.The facility's incident report for R1 dated 7/28/25 at 10:00 PM and entered by V10 (nurse) showed, . Received shift report from nurse. She stated she was having a problem with tubing. Checked on resident around 12:05 AM, vitals were stable. Earlier in the morning, resident had two small emesis. I noticed tube feeding was in different bag and disconnected. Was not sure if resident received correct feeding per orders. Notes: . On 7/28/25, nursing staff reported concerns regarding the resident's tube feeding set up. Later, during the night shift, the resident's tube feeding was found in a different bag and disconnected. The resident remained stable throughout the shift, and vitals were within normal limits. She did have two small emesis'. The incident was reported to DON, and the provider was notified.On 4/22/26 at 11:12 AM, V11 (R1's son) said, On 7/28/25 there was an issue with a tube feeding. This issue was brought to my attention when I came into the facility on the morning of 7/29/26. Even before I went into her room, I was pulled aside by the nurse (V5 Registered Nurse) who told me my mom was overfed, but she didn't know how it happened. she said she didn't know what happened but heard about it from the overnight nurse. Then the CNA (Certified Nursing Assistant) said something was wrong with mom, she took her to the shower, and she started to vomit, which was not like her. The CNA apparently found out through other staff that something happened with her feeding. The nurse used the term overfeeding . when I came in it was a bit alarming because as she was lying in bed and she was vomiting a little bit, gagging, and choking. I never could get quite down to the bottom of it. She went to the hospital the next day when she started to develop a fever and a bad cough with congestion. She became very lethargic and unresponsive. There was a Nurse Practitioner who came in because I said, 'hey, she aspirated because of this overfeeding' and he said he hadn't heard about that. when he had seen her, she was still pretty with it. when watching the videos from her room I saw the CNA say they fed her 2 times too much, or 2 times too fast. The wound nurse is the one who identified that her blood oxygen was starting to tank. They put her on oxygen, and shortly thereafter, they called 911 to get her to the hospital. When she was admitted to the hospital they called [the facility] and they told the hospital she was overfed. when I walked in that morning, there was new kind of pump in the room . it was different than they had ever used with my mom. I later learned there was confusion with the staff as to how to use that pump. I guess they weren't clear on setting the rate. When I walked in the room, the rate was set two times faster than what they normally did. Apparently one of the nurses thought this pump had an automatic flushing system in it and she tried to program it automatically flush the system as well. After this incident, she had an ongoing cough and obvious issues after that aspiration episode where her breathing wasn't good and after that she had to be on oxygen concentrator. I had continuous recording in her room, signs were posted at the door. I sent all the video and recordings about this incident. I think the information in these videos is pretty compelling. R1's Change of Condition form dated 7/29/25 entered at 4:34PM showed, The resident is experiencing a change in condition. See SBAR assessment for further information and family/physician notification. The change in condition the resident is currently experiencing is nausea, vomiting, chills, labored breathing, use of accessory muscles, diminished sounds at the bases. sputum bright yellow in color. HOB (head of bed) elevated Tylenol and Zofran (for nausea) given relief noted.R1's 7/30/25 Progress Note entered by the V15 (Nurse Practitioner) showed, Date of Service: 7/30/25; Visit Type: Acute. Chief Complaint: the patient was found in their room exhibiting signs of respiratory distress, with oxygen saturation below 80% on room air. Supplemental oxygen was administered, but it remained difficult to maintain saturation levels above 90%. A significant deterioration in the patient's medical condition was observed this morning. Decided to transport the patient to hospital for further evaluation and treatment.R1's Encounter Note entered by V15 (Nurse Practitioner) showed, the nurse reported that the patient is admitted to the hospital and diagnosed with aspiration pneumonia and a urinary tract infection.R1's Acute Care Hospital Documents dated 7/30/25 at 10:45AM showed, . Emergency Department Encounter. Chief Complaint: . cough, congestion, Patient comes from [the facility] and son has concerns she was overfed via her g tube and aspirated yesterday, patient has audible congestion. History of Present Illness: . Shortness of breath. fever. presents to the emergency department with cough, congestion, hypoxia, fever. Patient's son provides the history. Notes that the patient was accidentally given her tube feed as a bolus yesterday rather than over a 12- hour infusion, the staff noted that she was vomiting afterwards. Since then, patient has had significant cough and chest congestion. She was hypoxic at the facility, does not use oxygen at baseline. She has significant rhonchi and a congested cough. She is tachypneic and using accessory muscles to breathe. requested pulmonology consultation.R1's Acute Care Hospital Documents dated 7/30/25 at 2:58 PM showed, . History and Physical. Chief Complaint: Shortness of breath, hypoxia, nausea and emesis at skilled nursing facility after receiving bolus tube feed. The patient is unable to provide any history whatsoever due to previous CVA (Cerebrovascular Accident), so the history is obtained from my discussion with the emergency medicine physician. The patient was at her skilled nursing facility yesterday, when she was accidentally given bolus tube feeding instead of continuous infusion tube feeding. The patient apparently developed nausea and vomiting after receiving the bolus tube feeding. Today, the patient was noted to have cough and chest congestion and was hypoxic on room air, so the facility staff called 911. Assessment and Plan: Suspected aspiration pneumonia, with history of severe tracheobronchomalacia noted on previous CT scan. History of CVA with baseline dysphagia, status post G-tube placement, and probable dementia, with suspected aspiration at skilled nursing facility.R1's Acute Care Hospital Documents showed, . Pulmonary Inpatient Note. Chief Complaint. Cough, congestion, fever, shortness of breath. Presenting to the hospital 7/30/25 with cough, congestion, shortness of breath, fever. Patient resides at [the facility]. Patient was accidentally given her tube feed as a bolus yesterday and she started vomiting after. Since emesis episode, has ha a cough, congestion, lethargy. Assessment/Plan: Aspiration event, fever, aspiration pneumonia, tracheobronchomalacia.R1's 8/4/25 Physician Note showed, Date of Service: 8/4/25; Visit Type: History and Physical. Chief Complaint: I saw the patient for re-admit H & P (history and physical). She has been awake this morning, weak and confuse as she usually does early in the morning. She admitted to the hospital 7/30/25-8/2/25. She has been on continuous tube feeding, she had a bolus tube feeding accidentally instead of continuous feeding. She developed congestion, SOB (shortness of breath), and hypoxia O2 saturation 60%, required O2 per nasal cannula, later that day; she was taken to ER and found to have aspiration pneumonia. This was treated with intravenous antibiotics, and she tolerated low oxygen per nasal cannula. She was stabilized and discharged back to our rehab on continuous tube feeding.On 4/22/26 at 12:19 PM, V10 RN (Registered Nurse) said, What I remember from that is that the previous nurse had some confusion finding the tubing. The previous nurse had used the bag and I guess you can program it one bag for water and one for tube feeding I think she set it up that way. It was set up already. If I remember right the tube feedings ran through my whole shift. I wouldn't start it or end it. I think the machine was programmed to end, so I would just disconnect it after the machine ended. I remember she had one or two emesis. I saw one emesis, it looked like tube feeding.On 4/22/26 at 1:10 PM, V8 CNA (Certified Nursing Assistant) said, We did have some problems. Something happened the night before. I remember that her tube feeding was an oopsie, where she got her tube feeding too fast which caused her to be sick. I don't know if it was the nurse, like if it was an agency nurse, or someone that wasn't really familiar with her. she had the g-tube, but she could have orange juice, apple sauce, pudding, just for enjoyment, she would never eat a large quantity of it.On 4/22/26 at 1:19 PM, V9 CNA (Certified Nursing Assistant) said, I remember hearing that she got too much tube feeding. I don't know what happened on nights and evening shift. She was vomiting up stuff.On 5/6/26 at 10:11 AM, V15 (Nurse Practitioner) said, It was reported to me that she had been given bolus feeding accidentally. The level of risk for the patient depends on the amount of bolus feeding. If it was a small amount, it isn't as big of a deal, but the patient was not in the best condition at the time. We know that the patient was vomiting right after the bolus feeding. They should follow the order for it. It should be given as the order shows. That is why they follow the order, because of the risk of aspiration.On 5/6/26 at 11:21 AM, V2 DON (Director of Nursing) said, I know coming in that day, there was a big commotion because [R1's] son was there, and he was really mad. He had been talking to [V10], the night nurse. He was yelling at [V10]. I told him I didn't know what was going on, I would have to see. I started my investigation. At this particular time, [R1] was getting her feeding through the pump, it wasn't bolus. The nurse went to go get a bottle of feeding that has spikes to spike the bottle and it is hung right from the bottle. The nurse said she couldn't find the tubing that had the spike, so I had seen in there, there were two bags hung, one with tube feeding and one with water in it. She found the one with the two bags, so she put the feeding in the bag. She got a plain bag and put the tube feeding from the plastic bottle, and she put it in the bag. I talked to V6 and V10. I wanted to know how it was flushed. V6 and V10 both said they flushed it manually through the tube, because V10 had flushes to do on night shift and V6 had some to do on PMs. I showed [V6] where the supplies were and she said 'oh okay'. I did a skill's check on her, because I wanted to know that she could do it. I didn't look at the pump when I came in because it was stopped already. we had a meeting with the son, and I said I was going to educate the nurse on the whole process and supplies. [V10] called me in the morning to report it and I told him to put it in risk management. [V10] must have entered the time he came on shift as the risk management time because he didn't call me at 11:00 PM, he called me in the morning. When asked about what conclusion she came to during this investigation, V2 said she was trying to figure out [V10's] whole part in this situation. V2 said she spoke with V6 five times because she is hard to understand. V2 said she can't say [R1] did or didn't receive it the feeding correctly. It was already disconnected in the morning, so I was just trying to piece it together.On 5/6/26 at 10:58 AM, V13 (Physician/Medical Director) said, I remember this bolus feeding was given accidentally. It was supposed to be a rate feeding. people on rate feeding should not be given bolus feedings, bolus feeding is for someone who has no dysphagia or reflux. Bolus is not given to those people with dysphagia, so they give them a rate feeding (slower feed) to avoid reflux. The logic is that reflux causes aspiration pneumonia. Symptoms from receiving a bolus feeding instead of a rate feeding would include coughing, shortness of breath, vomiting (reflux), and that can cause aspiration pneumonia. [R1] was increased risk for aspiration.The facility's policy and procedure related to enteral tube feedings was requested. The facility provided a Skills Checklist titled Enteral Tube Feeding via Gravity which showed, . Check the enteral nutrition label against the order before administration. Add the following information: Resident Name, Type of Formula, Date and Time Formula was prepared, Rate of Administration (ML/HR). Check the order to verify the type, amount, method, and rate of administration.

Based on interview and record review the facility failed to safely transport a resident. This failure resulted in R1 falling from her wheelchair during the transport and sustaining a 5 centimeter (cm.) laceration to her forehead requiring emergency medical attention, 11 sutures and hospitalization. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 4. This past noncompliance occured from 3/16/26 to 3/23/26. Findings include: R1's face sheet shows R1's diagnoses including Alzheimer's Disease, muscle weakness, and a non-displaced type 2 dens fracture.R1's current care plan shows R1 is at risk of falls and requires staff assistance with toileting and transfers. R1's nursing progress note dated 3/16/26 at 9:12 PM, shows that R1 had a fall out of her wheelchair while being taken to the bathroom by a CNA (Certified Nursing Assistant). R1 fell forward out of her wheelchair and hit her face on the floor. A laceration was noted above R1's left eyebrow, 911 was called and R1 was sent to a local emergency room for treatment.A State Reportable Incident form completed by V2 (Director of Nursing) shows on 3/16/26 after the fall, R1 was transported to the emergency room and admitted for further diagnostic testing. R1 sustained a laceration to her left eyebrow requiring sutures. There was also a fracture to her C2 (odontoid) however imaging was unable to determine if this was a new or old fracture. The report shows that R1 propels herself in the wheelchair without footrests therefore footrests were not in use at the time of the fall. R1's History and Physical from a local community hospital shows R1 required sutures to her forehead laceration, and R1 had a prior C2 fracture in November 2025. The report shows a CT scan was done and states, Type II fracture of the dens with slight posterior displacement and slight posterior angulation. The fracture margins are somewhat indistinct, suggesting a nonacute fracture. R1's emergency room report shows 11 sutures were needed to close the laceration above R1's left eyebrow.R1's Electronic Medical Record (EMR) shows R1 returned to the facility on 3/21/26 with a cervical collar in place and sutures to her left forehead. On 4/20/26 at 9:56 AM, V2 said she completed an investigation of R1's fall and they determined during a root cause analysis that the cause of R1's fall was because R1 she did not have footrests on her wheelchair while being transported to the bathroom. R1 was told to hold her legs up while V3 pushed her but suddenly she put her feet down on the floor during the transport causing her to fall forward out of the chair. V2 said R1 propels herself around without footrests on her wheelchair at baseline but when staff are going to transport residents, they should put the footrests on prior and the CNA (V3) did not do so. V2 said R1 needed sutures after the fall, and the hospital could not determine if R1's C2 fracture was new or a previous one. On 4/20/26 at 10:10 AM, V3 (CNA) said I was pushing her (R1) in a wheelchair without her footrests on. It happened so fast and next thing I knew she was on the floor. I was going to toilet her. We should transport residents with footrests on their wheelchairs. I should have put the footrests on first, we were in- serviced right after making sure we put on the footrests.On 4/20/26 at 11:11 AM, V11 (Physical Therapist) said before residents are transported the staff should put footrests on wheelchairs, not all residents can hold their feet up that long.On 4/20/26 at 11:38 AM, R1 was sitting in her wheelchair by the nursing station with a neck collar on. R1 said, I had quite a fall yes, I don't remember a whole lot after, but I was being pushed to the bathroom by a CNA and I fell forward and out of the chair. I had a cut to my forehead and got sutures.The facility provided Skilled Fall Policy dated 5/2025 states, Each resident residing at this facility will be provided services and care that ensures that the resident's environment remains as free from accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents.Prior to the survey date of 4/20/26 the facility had taken the following action to correct the noncompliance.1. On 3/17/26 the facility Interdisciplinary team held a Root Cause Analysis meeting and immediately began a plan of correction after reviewing R1's fall. The facility informed R1's physician and Medical Director immediately. A comprehensive review of policies and interventions to be included were discussed.2. On 3/17/26 all facility staff that transport residents in wheelchairs were educated and in-serviced regarding footrests and transporting residents.3. R1's Care Plan was immediately updated. And she was re-assessed by Physical Therapy.4. All residents were audited for their need for footrests. And V2 did weekly audits for 4 weeks and then on-going monthly audits for 2 months to ensure staff are complying with residents safety interventions.5. All staff were in-serviced and the plan of correction date when the facility was in compliance was identified as 3/23/26. 6. Audit results were brought to the QAPI meeting on 4/14/26 and no new compliance was found.

Based on observation and interview the facility failed to ensure residents are treated with dignity and respect. This applies to 2 of 4 residents (R1, R2) reviewed for resident rights in the sample of 4. The findings include: On 12/2/25 at 9:24 AM, R1 was in her room sitting in her wheelchair, sitting next to her roommate R2. R1 said on 11/28/25, there was a young kid V3 (Agency CNA) who came into her room to assist her in the bathroom. R1 said it was the first time she had seen V3, he was wearing street clothes a black shirt, no name tag and did not introduce himself. R1 said he looked like he would be cleaning the floors wearing a black t-shirt with writing on it. I don't think that's professional attire, he did not announce who he was and just came into our room and took me to the bathroom. R1 said she felt uncomfortable, he didn't explain who he was and she did not know he was a CNA. On 12/2/25 at 9:28 AM, R2 was in her room sitting in her wheelchair, sitting next to R1. R2 said on 11/28/25, V3 entered the room, did not knock or introduce himself. V3 was not wearing a name tag and had a black t-shirt on that said class of 2023. V3 came in caressed his hand on my head down my face. R2 said she jerked back, and he removed his hand. R2 said she felt uncomfortable and surprised, he has no right to do that. She didn't know V3, and it seems agency staff are not qualified. She would expect staff to knock, identify themselves and treat the residents with more respect. R2 said V3 was asking me to guess his age and she thought the conversation was weird.On 12/2/25 at 11:23 AM, V3 (Agency Certified Nursing Assistant-CNA) said he was R1 and R2's aide on 11/28/25. Typically, he wears scrubs when working with his name tag. V3 confirmed he was a t-shirt that evening and said his name tag came off. He should knock on the door and introduce himself when he enters a room. V3 said he does not recall touching R2's hair or face while providing care.On 12/2/25 at 2:42 PM, V5 (CNA) said she was the night CNA on 11/28/25. V5 said some of the agency staff don't wear scrubs or name tags. That night V3 was wearing sweatpants and a t-shirt. R2 said V3 was petting her on the head and she did not like that. R1 reported V3 in street clothes and she felt uncomfortable not knowing who he was.On 12/2/25 at 11:54 AM, V6 (CNA) said R2 complained of V3 touching her face and feeling uncomfortable. Some of the agency staff wear street clothes and no name tag, residents have complained about this.On 12/2/25 at 1:07 PM, V1 (Administrator) said all staff should wear scrubs and their name tags including agency staff. They should identify themselves when entering the rooms and interact with residents in a respectful manner. R2 said she felt uncomfortable when V3 patted her on the head.

Based on interview and record review, the facility failed to ensure a resident's safety during an outdoor activity. This applies to 1 of 3 residents (R2) reviewed for safety and supervision in the sample of 5.The findings include:R2's electronic face sheet printed on 11/24/25 showed R2 has diagnoses including but not limited to type 2 diabetes, constipation, CHF, vascular dementia without behaviors, repeated falls, and peripheral vascular disease.R2's facility assessment dated [DATE] showed R2 had mild cognitive impairment.The facility's incident report dated 11/15/25 showed, This writer was notified by the weekend staff nursing supervisor that (R2) received a bite from a visiting domesticated horse and received a small laceration to the hand. The horse was under the supervision of its handler when the incident occurred .R2's progress notes dated 11/15/25 showed, Resident attempted to feed a horse during activities, but was accidently bit on the left 4th digit. She sustained an abrasion .resident was complaining of mild pain in the area rating the pain a 3/10.Area was cleansed with normal saline; bacitracin was applied with gauze. Since resident was previously started on oral antibiotics for a urinary tract infection, nurse practitioner stated that resident will be protected from the bite. She also ordered a TDAP (Tetanus, Diphtheria, and Pertussis vaccine to be given and to monitor resident vitals and report any abnormal vitals .R2's wound assessment dated [DATE] showed, Left fourth digit: wound measures 0.69x0.58x0.2cm with sanguineous (blood) drainage.On 11/21/25 at 11:32AM, V1 (Administrator) stated, We were trying to get the residents outside to do an activity so when (V10-Certified Nursing Assistant) volunteered to bring her horses here we thought it would be a good idea. In hindsight I guess we could have just had her ride the horse and show it and maybe have the residents pet the horse and not feed it. I think (R2) was just happy to be doing the activity and wasn't paying attention and the horse was eating out of her hand and then it bit her finger. I'm not sure how we really could have prevented it except for not having the residents hold the food in their hand. I don't think the horse has ever bit anyone before but maybe it just got nervous because it didn't know R2 or something.The facility was unable to provide a policy regarding resident safety during outdoor activities.

Based on interview and record review the facility failed to ensure a residents bed was maintained to ensure no hazards were present for one of three residents (R1) reviewed for injury in the sample of three. This failure resulted in R1 experiencing a large skin tear from exposed sharp metal on the bed, requiring R1 being sent to the local hospital and requiring 12 sutures to the wound.Findings include:R1's Face Sheet dated October 14, 2025, shows R1 was admitted to the facility on [DATE], with a diagnosis of senile degeneration of the brain. R1's Care Plan initiated September 1, 2025, shows R1 has an activity of daily living self-care performance deficit related to dementia and anxiety disorder. The facility's State Report dated October 8, 2025, shows on October 7, 2025, a certified nursing assistant (CNA) was transferring R1 from her wheelchair to her bed with a one-person assist per her care-plan. After R1 sat on the edge of the bed, the CNA observed fresh blood on the floor and noted that R1 had a laceration on her right lateral leg. The wound care nurse (WCN) assessed the area and applied pressure to control the bleeding. Once the bleeding was controlled, further assessment revealed that sutures might be required to close the wound. Orders were obtained for evaluation and treatment in the emergency room. Investigation determined that the laceration occurred when R1 rubbed her leg again an exposed area of the bed frame during transfer. It was identified that a round cap was missing from the bed frame.R1's Skin and Wound Evaluation dated August 31, 2025, shows R1 had a laceration to her right lateral calf that measured 4.7 cm (centimeters) long, 2.0 cm wide, and a depth of 0.4 cm. R1's laceration was draining a moderate amount of bloody drainage.R1's local hospital record dated October 7, 2025, shows R1 was seen in the local emergency room for a laceration received during a bed transfer. R1's wound was sutured and cleaned, however due to significant leg swelling and lymphedema, fluid was noted to be oozing from the wound. R1 was given a dose of intravenous antibiotic and topical antibiotic. On October 14, 2025, at 10:43 AM, V4 Licensed Practical Nurse (LPN) said she was on break in her car when the certified nursing assistant (CNA) called her. V4 said that when she got into R1's room, V3 Wound Care Nurse (WCN) was already in there. V4 said she did not know what happened, but it happened during the transfer. V4 said the laceration was big and deep, so R1 got sent out to the local emergency room. At 11:07 AM, V6 CNA said she took R1 to the bathroom then transferred R1 back into bed. V6 said when R1 was sitting on the side of the bed, she noticed that R1's leg was bleeding. V6 said R1's nurse was on break, so she called V3 WCN to come and assess R1's leg. V6 said R1's leg was bleeding a lot. V6 said there was blood on the floor. At 12:27 PM, V3 WCN said she was the first nurse that assessed R1. V3 said there was blood on the floor and R1 was sitting on the edge of the bed. V3 said R1 shifted her leg and exposed the metal on the bed frame. V3 said there was a moderate amount of bleeding to R1's leg. V3 put a dressing onto R1's leg. V3 said R1's wound was too deep to take care of at the facility, so she sent R1 to the local emergency room. V3 said R1 received sutures to her leg. V3 said there was a small amount of blood on the metal part of R1's bed. V3 said there was a flat circle knob that was missing from the metal bed frame and V3 believed that is where R1 scratched her leg. V3 said she called V5 Maintenance Director. At 10:51 AM, V5 Maintenance Director said R1's bed was missing a round black cap. V5 said this was the first time he heard of the missing cap and replaced it. On October 14, 2025, at 10:02 AM, R1 was laying in her bed. There was a large triangle shaped wound to the outer part of R1's leg with12 blue sutures in place to this wound. R1 said the wound hurts sometimes.The facility did not provide a polity documenting the facility checked the residents' beds on a routine basis.

Based on interview and record review the facility failed to ensure a resident remained free of sexual abuse. This applies to one of three residents (R5) in the sample of eight reviewed for abuse. Findings include:The facility face sheet for R5 shows diagnoses to include dementia and psychosis. The facility assessment dated [DATE] shows R5 to have severe cognitive impairment and requires maximum staff assistance with her activities of daily living, and uses a wheelchair for ambulation.The facility face sheet for R4 shows diagnoses to include Parkinson's Disease, depression and psychotic disorder. The facility assessment dated [DATE] shows R4 to be cognitively intact and requires supervision for his activities of daily living and uses a wheel chair for his ambulation. The facility state report dated 8/9/2025 shows an incident between R4 and R5 while in the dining room of the facility. A staff observed the two residents sitting closely to each other and the male residents (R4) arm was moving back and forth over the female residents (R5) lap. The staff then went and separated the residents and noticed R5's pants were unbuttoned and R4 left the area immediately after being asked what was going on. On 8/20/2025 at 11:00 AM, V4 Certified Nursing Assistant (CNA) said she was walking past the dining room and noticed R4 and R5 sitting real close to each other and R4 had his hand over R5's lap and was moving his hand back and forth. V4 said she walked into the dining room and asked R4 what he was doing. V4 said R4 backed up quickly and nearly fell out of his wheelchair and denied doing anything. V4 said she looked over at R5 and noticed her pants were unbuttoned. V4 said when she turned her attention back to R4, he was gone. V4 said she took R5 from the dining room and took her to the nurse and told them what she had seen. On 8/20/2025 at 11:10 AM, V3 Registered Nurse (RN) said V4 came to him with R5 and told him that R4 and R5 were seen sitting very close to each other and R4's hand was moving over R5's lap and R5's pants were unbuttoned. V3 said he immediately called the Administrator and the Director of Nursing and assessed R5 for any harm.On 8/20/2025 at 1:30 PM, V1 Administrator said he was notified of the incident the day it happened, and he notified the police right away. V1 said R4 was placed on a one-to-one observation and will remain on one until an alternate living arrangement can be made. The care plan for R4 dated 3/25/25 shows R4 was showing interest in a female peer and would sit outside her room and try to enter her room. Interventions were put into place. On 6/24/25 R4's care plan was updated to show the potential to be inappropriately touching another female resident. R4's care plan was updated again with new interventions put into place. (A state report dated 6/24/25 shows this was R5. An investigation was completed and could not be substantiated.)The undated facility policy for abuse prevention shows each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone including other residents.

Based on interview and record review the facility failed to perform thorough pressure ulcer assessments and initiate a baseline care plan for a resident admitted to the facility with a pressure ulcer for 1 of 1 residents (R1) reviewed for pressure ulcers in the sample of 4. Findings include: R1's Facesheet dated 4/24/25 showed she was admitted to the facility 10/28/24 with diagnoses to include, but not limited to: COVID-19, generalized muscle weakness, hypothyroidism, diabetes, gastro-espophageal reflux disease (GERD), unspecified cirrhosis of the liver, and gout. R1's Nursing Admission Assessment completed dated 10/28/24 showed she had pressure to her sacrum. This document did not provide any further description or measurements of R1's pressure ulcer to her sacrum. R1's Progress Notes did not contain a detailed pressure ulcer assessment for R1's initial pressure ulcer and weekly assessment. R1's Electronic Medical Record (EMR) did not contained a thorough initial or weekly assessment of R1's pressure wound to her sacrum. R1's Skin Check Weekly dated 10/28/24 showed R1 had an open area to her sacrum, but there was no further assessment of the wound (i.e. measurements, appearance, wound bed, wound edges, drainage, etc.) R1's Physician Order Sheet dated 4/24/25 showed there was an order for a wound care consult dated 10/28/24 and orders for wound care to the scarum dated 10/28/24. R1's Skin Integrity Care Plan wasn't imitated until 11/4/24 (8 days after admission) and the related to details were not completed. This care plan showed interventions to include: Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. On 4/25/25 at 1:43 PM, V7 (Registered Nurse - RN) said the floor nurse completes an admission assessment on all new admits. V7 said the wound care process had changed about a month ago. V7 said in October 2024 the floor nurse would do an initial skin assessment and chart any findings. V7 stated, If there was a wound, then the nurse should describe it to the best of her ability. Now we don't stage pressure wounds and we have to notify the Wound Care Nurse (WCN). The WCN will complete a detailed assessment. The floor nurse should provide measurements, location of the wound, and a basic description of the wound and any drainage. (The surveyor directed V7 to review R1's Admission Assessment and asked what R1's wound looked like.) There is no way to know what it looked like because it just says pressure. (The surveyor asked V7 if she saw any detailed Wound Assessment for R1's sacral pressure wound.) I don't see anything here. V7 said proper documentation of the wound assessment is an important for tracking the wounds progress and ensuring continuity of care for the R1. V7 said she is unsure who initiates the baseline care plan for residents. V7 stated, I think MDS (Minimum Data Set) does that? I really can't speak on it. I don't remember every doing that. On 4/25/25 at 2:00 PM, V4 (WCN) said she started with the facility around the third week of February 2025. V4 said she was not working at the facility when R1 was there. V4 said all new admissions should have an initial skin assessment. V4 said if it is during them week, the nurse will notify her if there is a wound and she usually does a thorough wound assessment within 24 hours. V4 said the floor nurse can provide a basic description, including the location, size, appearance of the wound and if there is any drainage. V4 said the initial wound assessment is important to track the wounds progress, determine if the treatments regimen needed to be altered, and to prevent the risk of infection. The surveyor showed V4, R1's Admission assessment dated [DATE] that showed, pressure, to the sacrum and R1's Skin Assessment Weekly dated 10/28/24 that showed R1 had an open area to her sacrum. The surveyor asked V4 if R1's documentation provided the proper assessment details of a pressure wound. V4 replied, Absolutely not. The baseline assessment is very important, so everyone knows the starting point. V4 said a proper wound assessments includes: measurements; location; description of the wound bed and wound edges; staging for pressure ulcers; and a description of drainage. V4 said if R1 had a pressure wound on admission, then R1 should have had a baseline care plan initiated within 24 hours to address R1's individualized care needs. V4 said the Care plan is a tool to communicate the R1's care needs to the care team. On 4/25/25 at 2:21 PM, V2 (Director of Nursing - DON) said she did not recall R1, but she was looking through R1's record for Skin Assessments. R1 provided the Skin Assessment Weekly dated 10/28/24 (showing an open wound to R1's sacrum, but no further description of the wound). V2 said there should be a detailed initial pressure ulcer assessment and weekly pressure ulcer assessment. V2 said based the information documented, there was no way to know what R1's sacral pressure ulcer looked like. V2 said the facility does not use shower sheets and she had reviewed all the possible places the nurse should have documented a thorough wound assessment. V2 said she could not locate one. V2 said a baseline care plan should be initiated within 24-48 hours of admission. V2 said R1's Admission Assessment showed she had pressure to her sacrum, so R1's care plan should have reflected there was a skin integrity concern. V2 stated, I do see a wound care consult ordered. There isn't usually a Wound Care consult unless the resident had a wound. The whole thing is very confusing. The facility's Pressure Injury Assessment and Treatment Policy dated 1/2025 showed, The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified alterations in skin integrity, pressure injuries, and the prevention of acquiring additional alterations in resident skin integrity . General Guidelines: A. The pressure injury treatment program should focus on the following strategies: a. Evaluating the resident, understanding current risk level, and/or the status of existing skin alteration and/or pressure injuries .Documentation: The following information should be recorded in the resident's electronic medical record. A. Document type of wound and location: a. Stage of the wound in pressure. b. Use anatomical location in description. B. Partial thickness or Full thickness. C. Wound measurements: a. Head to toe (Length). b. Left to right (Width). c. Depth. D. Undermining, tunneling, or sinus tract: a. Clock method (12 o'clock represents residents head, 6 o'clock represents resident's feet. E. Exudate (Drainage): a. Type. b. Color. c. Amount. d. Odor. i. Absence or presence of odor and describe the smell. F. Wound bed: a. Adherence of tissue (slough or eschar). b. Types of tissue visualized in wound bed. c. Amount of visible tissue: i. Describe in percentage amounts tissue types that make up the wound bed. ii. Can you use the clock system to describe location of varying tissue types. d. Debris or foreign bodies. G. Describe wound edges: a. Definition (defined or undefined). b. Attachment. c. Border shape. d. Maceration, epibole, fibrotic, callused etc. H. Describe Peri-Wound (Surrounding tissue). I. Describe any indications of possible infection. J. Pain: a. Causative factors. b. Duration. c. Intensity. d. Intervention for pain relief and effectiveness. K.Document interventions for healing .

Based on observation, interview, and record review the facility failed to ensure correct food service scoops were used to serve mashed potatoes. This has the potential to affect all 73 residents in the facility. Findings include: Facility Data Sheet dated 4/15/25 shows the facility has a total census of 73 residents. On 4/15/25 at 12:10 PM, V1 (Interim Administrator) said the facility does not currently have any residents that receive a tube feeding or have an order of NPO (nothing by mouth). On 4/15/25 at 11:40 AM, V4 (Cook) said the food supplier did not bring the lunch meal on time to serve the country fried steak on Monday. V4 said for lunch on 4/15/25 they will be serving country fried steak with gravy, mashed potatoes, gravy, and a breadstick. V4 said V4 and other cooks usually get the scoops set up and ready for serving and the dietary aides will serve lunch. V4 showed this surveyor where the binder was that listed the portion and scoop sizes to use for each meal and stated that the dietary aides also know where it is and have access to it when needed. On 4/15/25 at 11:25 AM, V4 placed a green handled number 12 scoop (which provides 2 2/3 ounces) into the mashed potatoes. On 4/15/25 at 11:38 AM, V7 (Dietary Aide) started service, providing one scoop of mashed potatoes to every single plate. Facility diet spreadsheet shows the portion size for mashed potatoes is 4 ounces. On 4/15/25 at 11:47 AM, V11 (Regional Director of Operations- Kitchen) said the menus and recipes should be followed, including using the appropriate scoop listed. If the menus are followed as written, the nutritional needs of the residents should be met. Facility Standardized Recipes policy (no date) states, Standardized recipes will be used for all menu items, including pureed and therapeutic diets . 1. Each standardized recipe will include the following: . g. Serving sizes.

Based on observation, interview, and record review the facility failed to ensure employees practiced safe food handling practices resulting in risks of cross-contamination. This has the potential to affect all 73 residents in the facility. Findings include: Facility Data Sheet dated 4/15/25 shows the facility has a total census of 73 residents. On 4/15/25 at 12:10 PM, V1 (Interim Administrator) said the facility does not currently have any residents that receive a tube feeding or have an order of NPO (nothing by mouth). 1. On 4/15/25 between 9:15 AM and 9:30 AM, V7 (Dietary Aide) was continually observed doing dishes at the dish machine wearing gloves. V7 started by breaking down breakfast trays, discarding food debris and waste, and placing all trays, plate tops, cups, and utensils into dish racks. When the dish rack was full, V7 would place the dish rack into the dish machine and pull down the handle to run the automatic run cycle. When the cycle finished, V7 would pull the dish rack out of the dish machine and place the rack on the out-feed table to dry. V7 continued this process until the out-feed table became full with clean and sanitized dish racks. After handling the dirty dishes and without changing gloves or washing hands, V7 proceeded to remove the clean and sanitized dishes from the dish racks and put the clean and sanitized dishes away. On 4/15/25 at 10:50 AM, V4 (Cook) said all employees should wash hands after handling dirty dishes before touching clean and sanitized dishes. Facility Dish Machine Operation policy (no date) states, The Dining Services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food . 7. Follow the procedure for proper preparation and loading of dishes into the dishwashing machine. The standard sequence is as follows: c. Stack dishes in racks using correct procedure for that style rack . f. Use clean, washed hands to pull out clean racks, and allow to air dry before putting dishes away for storage . 2. On 4/15/25 at 9:03 AM, V4 started washing pots and pans in the three-compartment sink. V4 would use the first sink to wash all items with soap and water, the second sink to rinse with plain water, and the third sink to sanitize with a pre-diluted mixture of water and sanitizer. V4 washed a total of 7 pans, placed them in the middle sink to rinse, and dipped the pans into the third sanitizing sink for less than ten seconds each before placing them to the side to air dry. On 4/15/25 at 9:22 AM, V5 (Dietary Aide) and V6 (Dietary Aide) were cleaning up the beverage carts that were sent to the units for breakfast. V5 grabbed a clear two inch pan filled with ice and water and brought it to the dish machine area to show V6 how to clean the pans. V5 dumped the ice and water into a nearby sink, then proceeded to dip the clear pans into the third, sanitizer sink and immediately pulled them out and placed them to air dry. V5 and V6 continued this process with four clear pans and some coffee pitchers. On 4/15/25 at 10:50 AM, V4 said all items placed in the sanitizer sink should remain submerged for at least one minute for them to be fully sanitized. 3. On 4/15/25 at 10:12 AM, a visibly soiled food service scoop was stored inside the bulk flour storage bin, resting inside of the flour. On 4/15/25 at 10:50 AM, V4 said scoops should not be stored inside of bins. Facility provided Utensil Storage policy (no date) states, Employees will store utensils, tableware, and equipment according to the following guidelines . 5. Cleaned and sanitized equipment and utensils should be handled in a way that protects them from contamination . 4. On 4/15/25 at 8:54 AM, there were eight serving pitchers in the reach in cooler that contained a variety of juices and lemonade that were not labeled or dated. On 4/15/25 at 9:26 AM, V5 and V6 were cleaning up the beverage carts that were sent to the units for breakfast. V5 told V6, We are supposed to label these (juice and milk pitchers). I don't know why they are not labeled. On 4/15/25 at 10:50 AM, V4 said all items in the fridge should be labeled and dated.

Based on observation, interview, and record review the facility failed to ensure dietary staff are properly trained. This has the potential to affect all 73 residents in the facility. Findings include: Facility Data Sheet dated 4/15/25 shows the facility has a total census of 73 residents. On 4/15/25 at 12:10 PM, V1 (Interim Administrator) said the facility does not currently have any residents that receive a tube feeding or have an order of NPO (nothing by mouth). On 4/15/25 at 8:30 AM, V1 said the facility does not currently have a dietary manager and V8 (Former Dietary Manager) left approximately two to three weeks ago. On 4/15/25 at 11:00 AM, V11 (Regional Director of Operations- Kitchen) said he and his company have been overseeing the facility since July or August of 2024. V11 said the facility is responsible for hiring and training their own in-house employees including dietary aides, cooks, and a dietary manager. V11 said his company provides the facility access to a menu program that provides menus, recipes, tray tickets, policies and procedures, and education material. Since V11 has been working with the facility, V11 said there have been four dietary managers that V11 has helped train and the longest employed manager stayed for approximately two to three months. On 4/15/25 at 10:50 AM, V4 (Cook) said V8 was providing training to the newly hired employees, including V6 (Dietary Aide). V4 does not provide any training unless V4 were asked to train employees. On 4/15/25 at 12:55 PM, V3 (Assistant Administrator) said when V8 left, V1 and V3 started assuming some of V8's operational duties to ensure the kitchen was able to provide the residents with meals with no concerns. V3 said to train the newer employees, V3 is having more senior workers, like V7 (Dietary Aide) provide training to the newer employees. On 4/15/25 at 10:06 AM, V7 said she has been working at the facility for almost two years. On 4/15/25 between 9:15 AM and 9:30 AM, V7 was doing dishes at the dish machine. V7 started by handling dirty trays from breakfast with gloves on, placing the dirty plates and utensils onto a dish rack, and run the dish rack through the dish machine. When the dishes were finished being washed and sanitized, V7 removed the rack from the dish machine and continued this process until there was no more room on the out-feed table to place racks of clean and sanitized dishes. Without removing the gloves from handling the dirty dishes, V7 proceeded to empty the dish racks with clean and sanitized dishes and started to put them away. On 4/15/25 at 9:22 AM, V6 said she started working at the facility on 4/14/25. V5 (Dietary Aide) was training V6 how to clean up the beverage carts after breakfast. V5 instructed V6 to take a clear, two-inch pan full of ice and water, dump the ice and water into a nearby sink, then dip the pan into the third sink (sanitizer sink) of the three-compartment sink. V5 and V6 repeated this process for a total of four pans. None of the pans were left in the sanitizer sink for at least one minute. After the pans, V5 and V6 began emptying coffee pitchers from breakfast. V5 told V6 that the middle sink in the set-up and ready three-compartment sink was known as the dumping sink where employees discard leftover liquids from cups and pitchers before washing them. V5 asked V7 if that was correct and V7 agreed. When V5 asked V4, V4 said that the middle sink was not for dumping discarded liquids into and was for rinsing already washed dishes. On 4/15/25 at 10:50 AM, V4 said staff should wash hands when going from dirty dishes to clean dishes. Facility did not have a policy and procedure related to required dietary staff training. Facility Dish Machine Operation policy (no date) states, The Dining Services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food . 7. Follow the procedure for proper preparation and loading of dishes into the dishwashing machine. The standard sequence is as follows: c. Stack dishes in racks using correct procedure for that style rack . f. Use clean, washed hands to pull out clean racks, and allow to air dry before putting dishes away for storage .

Based on interview, and record review the facility failed to ensure a resident was free from misappropriation. This applies to 1 of 4 residents (R1) reviewed for misappropriation in the sample of 4. The findings include: R1's Minimum Data Set, dated dated dated [DATE] shows R1 scored a 15 out of 15 on her brief interview for mental status test indicating R1 is cognitively intact. On 2/24/25 at 10:00 AM, R1 said during the week of February 10th through February 15th, V4 (R1's Family Member) visited and gave R1 two twenty-dollar bills. R1 said she placed the two bills with the rest of R1's money in the side pocket of her purse that uses a drawstring to close. On 2/24/25 at 11:53 AM, V4 said after giving R1 the money, R1 and V4 counted the money together and V4 watched R1 put the money into the side pocket of the purse and closed the drawstring closure. Facility sign-in sheet for visitors shows that V4 visited R1 on 2/11/25 and again on 2/14/25. On 2/24/25 at 10:00 AM, R1 said on the morning of 2/15/25, R1 asked V5 (Agency Certified Nursing Assistant- Agency CNA) to grab R1's purse from the floor to give money to V5 to go to the vending machine for R1 and purchase a water and a package of cookies. When V5 gave R1 her purse, R1 opened the side pocket with the drawstring and immediately noticed the two twenty-dollar bills were not in the pocket. V5 said V5 helped R1 search R1's purse and immediate surrounding in R1's room, but the money could not be found. On 2/24/25 at 11:27 AM, V6 (RN Supervisor) said V5 reported the missing money to V6 and V6 immediately notified V2 (Assistant Administrator) who was working as the manager on duty for the weekend. V2 along with V1 (Administrator) notified the local police and state agency of the incident and conducted an investigation thereafter. On 2/24/25 at 10:40 AM, V1 said after discussing the incident with R1, R1 believed V5 stole R1's money, but could not determine when. V1 said V5 was immediately suspended pending the investigation and V3 (Director of Nursing) placed V5 on the Do Not Return list with V5's staffing agency. V1 reimbursed R1 the missing forty dollars and R1 was appreciative. On 2/24/25 at 11:37 AM, V5 denied taking R1's money but corroborated helping R1 search R1's purse and room for the missing money. Facility Abuse, Prevention, & Prohibition Policy dated 12/2024 states, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals . Misappropriation of Resident Property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on observation, interview, and record review the facility failed to ensure care was provided to a resident in a dignified manner for 1 of 3 residents (R3) reviewed for resident rights in the sample of 6. The findings include: On 1/8/25 at 10:12 AM, R3 was sitting up in bed. R3 said she had been on isolation for COVID. R3 said one night a CNA (Certified Nursing Assistant - V11) came in her room. R3 stated, I don't know her name, but I think [V1 - Administrator] knows it. I talked to her (V1) about it. Anyways, the CNA was changing me and I told her that I have pain in my knees and she needs turn me at pushing on my hips. She kept pushing on my legs and it hurt, so I was telling her not to touch my knees. She kept making comments that she had a headache and I was yelling. I wasn't yelling, but I was letting her know that she was hurting my legs. When she turned me, she made a comment about me being a very big girl. I know I'm overweight and I don't need to be reminded. I thought that was a rude comment. The CNA wasn't wearing a name tag, so I asked her what her name was and she told me, I don't have to tell you that. She never told me her name. I have the right to ask anyone who comes in my room to identify themselves. I just felt like she was terribly rude. The care was rushed, she wasn't listening to me, the fat comment, and then she refused to give me her name. I called the front desk and reported it to [V12 - LPN]. Then [V1 - Administrator] came to speak with me. [V1] told me that the CNA would not be coming back to the facility. R3's Face Sheet dated 1/7/25 showed she had diagnoses to include, but not limited to: polyosteoarthritis, generalized muscle weakness, COVID-19, lymphedema, history of cancer, obesity, irritable bowel syndrome, and schizoaffective disorder. R3's facility assessment dated [DATE] showed she was cognitively intact. R3's Psychiatry Initial Evaluation dated 12/3/24 showed, Resident reports being distrustful of unfamiliar staff. Recently experienced an episode of panic when evaluated by an unknown person . R3's Alteration in Pain Care Plan revised 4/17/24 showed, R3 has an alteration in comfort, pain associated with obesity, immobility, polyosteoarthritis, lymphedema and depression . Interventions: . R3 is able to: call for assistance when in pain, ask for medication, tell you how much pain she is experiencing, tell you what increase or alleviates pain . The facility's undated Investigative Summary showed on 12/29/24, R3 who is alert and oriented x 4 (to person, place, time, and situation) reported that a CNA on night shift did not speak to her respectfully. The agency CNA (V11) was not scheduled to return to the facility. According to the schedule the CNA was V11. This report showed R3 reported V11 was not wearing her name badge and refused to identify herself. R3 said V11 stated, I don't have to give you my name. R3 said V11 was very rude and made a comment about R3 being a big girl, during cares. The report showed R3 did not feel it was abuse, but it was rude and didn't want V11 provided further care for her. On 1/7/25 at 12:35 PM, V9 and V10 (CNAs) said the staff are supposed to wear their name badges at all times. V10 stated, They are part of our uniform. V9 and V10 said the agency staff rarely wear name tags. They said the facility had sticker name tags that can be filled out, when you forget your badge. They said if a resident asks your name, then you can't refuse to tell them. They said the resident's have the right to know who is providing care to them. On 1/7/25 at 3:11 PM, V3 (DON - Director of Nursing) said all staff should be wearing name badges at all times. V3 said the facility uses agency staffing for CNAs and nurses and there seems to be a problem with agency staff wearing a name badge. V3 stated, I've call [the agency] numerous times about their staff wearing name badges when working. The agency staff are always telling me they forgot it or they don't have one. It drives me nuts. We have sticker name badges at the Receptionist desk and they can write their name on it. There is no excuse to not have one. It is part of their uniform and they know it. If they don't wear a badge and a resident asks their name, then they should tell the resident their name. So the resident isn't afraid and knows that the person actually works here. This is the resident's home and they have the right to know who is providing their care. On 1/8/25 at 10:51 AM, V12 (LPN - Licensed Practical Nurse) said at the end of her shift on 12/29/24 she received a call from R3. V12 said R3 reported her CNA was very rude and mentioned something about R3's weight. The CNA (V11) said R3 was yelling at her, but R3 is usually pretty soft spoken. V12 said it was the end of the shift so, she and V11 (Agency CNA) were preparing to leave for the day. V12 said R3 reported V11 was very rude, so she notified V1 (Administrator). V12 said the agency staff rarely wear name badges. V12 said she's worked for an agency before and they provide you with a badge after you work a few shifts. V12 stated, There's no excuse for not having a name tag on. If you forget to wear yours, then we have sticker name tags at the front desk. V12 said V11 should have told R3 her name because the resident's have the right to know who is working. The surveyor asked V12 if a staff member should tell a resident they are a big girl during care. V12 replied, Absolutely not! That's rude and disrespectful. V12 said R3 is alert and oriented and able to make her needs known. V12 said the facility utilizes a lot of agency staff and it's hard to keep them straight. V12 said she isn't familiar with V11 and doesn't know how she interacts with residents. On 1/8/25 at 1:38 PM, V1 (Administrator) said on 12/29/24 was notified by V12 (LPN) that R3 complained that her CNA (V11) was rude during the night. V1 said R3 reported that V11 had been rude to her, wouldn't tell R3 her name, and commented that she was a big girl. V1 said all staff should be wearing name tags while working. V1 said there are disposable name tags available, so there is really no excuse. V1 said if a resident asks the staff's name, then they should provide it. The surveyor asked if V11 should have made the big girl comment to R3 during care. V1 replied, She absolutely shouldn't have made that comment. It's a dignity issue and no one wants to be treated that way. You should speak to others how you want to be spoke to. [V11] will not be returning to this facility. The facility's Abuse Investigation file include an email to All staff dated 1/2/25 that showed, Please remember to always wear your name tag. Remember that this is our resident's home, and we must treat them with dignity and respect. Wearing your name tag ensures that they know who is providing care for them and helps them feel safe. The facility's undated Uniforms and Name Tags policy showed, .Name tags should be worn at all times when working in the facility so that our residents and families can easily identify our staff. The facility's undated Resident Rights' Policy showed, Your rights to safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction with yourself, at their highest practical levels .

Based on observation, interview, and record review the facility failed to ensure a resident's was free of misappropriation for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. The findings include: On 1/7/25 at 10:13 AM, R2 was sitting up in bed with her cell phone resting on the overbed table, in front of her. R2 said on 12/28/24 she was taking a nap. R2 said she woke up and her cell phone was missing. R2 said she figured (V4 - Agency CNA (Certified Nursing Assistant) had it, but she wasn't sure. R2 stated, The first time she saw [V4] was 4 days before. She (V4) asked me if she could use my phone and I gave her permission that day, but she used it in front of me. Then she came back on 12/28/24 and asked me if she could use my phone. I told her no a few times. When I woke up from my nap, my cell phone was gone. I called the CNA to report my cell phone was gone and she looked all over the place. They looked and looked and couldn't find it. I told the CNA (I don't remember her name) that V4 had it. I knew she took it. The CNA told me they couldn't find [V4]. Then the nurse (V5 - RN) came in and asked me if I gave [V4-CNA] permission to take my phone and I told him I did not. At some point they called the police. I didn't want to get that girl (V4) in trouble. She seemed like she may of had something wrong with her, like bipolar or something and I didn't want her to get messed up with the law. Everyone deserves a second chance. Then [V4] came back in room and the nurse was telling her she had to leave. She was standing over here in this corner (pointed to the corner, near the window on the far side of the resident room and to the right of R2's bed). She was moving around like she was trapped or something. She insisted that she had to use my phone again to punch out. I guess she put some app (application) on there. The nurse told her she couldn't use my phone and she needed to leave, but she picked up my phone again and said she removed the app. It was a wild situation. Then the police came and checked my phone. They said it looked like she made several phone calls, but I didn't want to press charges. It wasn't right what she did, but I don't want anyone to get wrapped up with the law. The surveyor asked if R2 had any personal information on her cell phone. R2 replied, It's my daughter's old phone, so I'm not sure. I don't know what's on there. I know my daughter was worried about that. It was so wild, [V4] didn't even try to deny she took my phone without permission. It seemed like she didn't understand what she did was wrong. I feel sorry for people that have disability. I guess I'm just too trusting. I didn't know all that information can be stored in a phone. If she (V4) was such a crook, then why did they hire her? R2's Face Sheet dated 1/7/25 showed diagnoses to include, but not limited to congestive heart failure, generalized muscle weakness, major depressive disorder, chronic pain syndrome, lymphedema, COPD (Chronic Obstructive Respiratory Disease), and morbid obesity. R2's facility assessment dated [DATE] showed she was cognitively intact. R2's progress notes were reviewed and did not contain any notes regarding this incident. The facility's undated Investigation Summary showed, R2 was alert and oriented x4 (to person, place, time, and situation). This report showed that V5 (RN) reported that V4 (Agency CNA) took R2's phone (without permission) and used R2's cell phone in her car. This report showed V4 (Agency CNA) admitted she had taken the phone, but she had returned it. This report showed that V5 educated V4 (Agency CNA) that she was not allowed to take resident's belongings for any reason. This report showed V4 replied, everything is okay now. This report showed that the police were called and V4 (Agency CNA) was escorted out of the facility (and was not allowed to return to the facility). R2 reported that she awoke from a nap and noticed her cell phone was missing. R2 reported she knew V4 was working and thought V4 took her phone. The facility's Abuse Investigation file for R2 include an email to All Staff, dated 1/1/25 that stated, Under no circumstances is it allowable to use a resident's personal belongings: including but not limited to cellphones. Under no circumstances should a resident's cell phone be used by staff to make calls, access apps, or send texts for their own personal use. On 1/7/25 at 3:11 PM, V3 (DON) said she was not present the day V4 took R2's cell phone, but she received a phone call from V7 (ADON). V3 said V7 reported V4 went into R2's room, took her cell phone (without permission) and used R2's cell phone in the parking lot. V3 stated, I couldn't believe it? How did she (V4) think it was acceptable to do that? I was on the phone with [V7-ADON] and could hear the Agency CNA's (V4) crazy answers over the phone. Apparently [V4] downloaded her agency staffing app onto [R2's] phone and used the phone in her car. She (V4) didn't seem to see anything wrong with that. She (V4) only worked here one other day and that was it. I DNR'd (Do Not Return) her from the facility. The resident's cell phone is their personal property and the staff should never ask to use their phones for any reason. We have computers and phones at the facility. She shouldn't have done that. It's unacceptable. On 1/8/25 at 10:27 AM, V5 (RN) said he worked 12/28/24, when the Agency CNA (V4) took R2's cell phone. V5 stated, [R2] reported to me that she didn't give (V4) permission. When I left [R2's] room CNAs (unable to recall their names) approached me and told me the same thing. I had already been having issues with her (V4) staying in the building that shift. She kept going in and out of the facility or in the break room and I was having a hard time keeping track of her. I told her (V4) that she had to remain near her assigned unit. Then this happened. I found [V4] and asked her if she took [R2's phone] and she admitted she took the phone. I told her that she isn't allowed to do that and V4 stated, I gave the phone back, everything is okay now. I guess the resident had let (V4) use her phone once before. Then V18 (R2's family member) called the facility and she had been trying to call [R2]. V5 said V7 (ADON - Assistant Director of Nursing) was the Manager on call that weekend, so he notified her. V5 said V18 (R2's family member) was concerned that V4 accessed private information in R2's phone. V5 said at some point the police were called and V7 (ADON) told him to escort V4 out of the building. V5 said he told V4 she had to leave and she started acting squirrely, and said she had to take her work app off R2's phone. V5 said V4 went in R2's room and picked up R2's phone again. V5 said he repeatedly told V4 that she was not to touch R2's phone and the facility would take care of her punch out with the agency. V5 said R2 told him V4 did not have permission to download an app on her phone. V5 said he finally got V4 (Agency CNA) out of R2's room and walked her to the lobby, but V4 was refusing to leave and demanding to be paid on the spot. V5 said he tried to explain the process to V4, but she said he was stalking her. V5 said he explained that was not the case, but he had to ensure she left the facility. V5 said he got a phone call from at the front desk and at that point V4 (Agency CNA) took the opportunity to leave the building. V5 said V4 sat in her car, in the parking lot for a while, but left when the police came. V5 said the police met with R2 and looked at her phone. V5 stated, She (V4) really didn't think there was anything wrong with it. It was crazy. I've been a nurse for a long time and I've never seen anything like it. On 1/8/25 at 10:36 AM, V6 (Restorative Aide) said V5 (RN) asked her to go with him to escort an Agency CNA (V4) out of the building. V6 said V5 (RN) told V4 (Agency CNA) that you can't touch R2's cell phone, but she did it anyway. V6 said V4 just went by R2's bed and grabbed the cell phone. V6 said R2 didn't give V4 permission. V6 said V4 (Agency CNA) was concerned with clocking out, on the staffing app that she had downloaded on R2's phone. V6 said V5 was telling V4 that the facility would handle her clock out, but V4 wouldn't listen. V6 said V4 (Agency CNA) said to R2, You let me use it before, and R2 replied, I did then, but not today. I told you no. V6 said the facility staff should never use a resident's cell phone for personal use. V6 stated, It's a known rule that we don't use any of the resident's belongings. That belongs to the resident. I don't know how she (V4) thought it was okay. On 1/8/25 at 11:14 AM, V7 (ADON) said she was on call 12/28/24 and V5 notified her that V4 (Agency CNA) took R2's cell phone without permission. V7 said V5 told her that R2's family was upset and wanted to talk to management. V7 said V18 (R2's family member) had called R2's cell phone numerous times and R2 did not answer, but finally R2 answered her phone and told her that V4 (Agency CNA) took her phone. V7 said V18 (R2's family member) was concerned about the possibility of V4 (Agency CNA) tried to steal banking information or personal information from R2's phone. V7 said it's unacceptable for staff to take anything that belongs to the resident. V7 said V5 (RN) reported that V4 (Agency CNA) kept disappearing and was difficult to keep track of. V7 said V4 returned R2's phone and didn't seem to think she did anything wrong, then she went back and grabbed R2's phone again because she needed to clock out and delete the staffing app. V7 said V5 (RN) was able to get V4 (Agency CNA) out of R2's room, then V4 started calling the on-call phone. V7 said V4 called from a different number, so she obviously had access to a cell phone. V7 stated, [V4] kept stalling and it didn't seem right. The police told us to detain her, but we're not allowed to do that. She eventually went out to her car, but she sat out there. She didn't leave until the police came. The facility has phones and computers that she could have used. There is no reason for her to be asking a resident to use their phone. She (V4) only worked here 1 other day and didn't even make it through half of that shift. It's crazy that it happened, then she refused to leave and demanded to get paid. It's all just crazy. On 1/8/25 at 12:50 PM, V18 (R2's family member) said on 12/28/24 she attempted to call R2 10+ times. V18 said someone picked up, but would hang up the phone. V18 said she was getting concerned, then R2 finally picked up and was yelling, She stole my phone. V18 said R2 told her that V4 (Agency CNA) had asked to use R2's phone multiple times on 12/28/24, but R2 said No. V18 said R2 said she took a nap and when she woke up her phone was gone. V18 stated, That's when I called the facility. V18 said she works in the industry and knows what should be done in this time of situation. V18 said she told the facility to handle it or she would. V18 said the police checked R2's phone and told her that V4 made several phone calls and attempted to access a cash app on her phone. V18 said she has passwords protection in place, so V4 was not able to get any money. V18 said the police told her that they called the numbers V4 (Agency CNA) had called and she was asking them for money. V18 said R2 is too trusting and believes everyone deserves a second chance. V18 stated, I tried to explain to her what information is on cell phones and that she (V4) had attempted to access my money. [R2] doesn't like that V4 (Agency CNA) had to be involved with the police, but I explained that we were aware enough to stop it before she got anything, but she may get away with it for other unsuspecting, vulnerable people. On 1/8/25 at 1:38 PM, V1 (Administrator) said there was no doubt that V4 (Agency CNA) took R2's phone, used it in her care, and made personal phone calls. V1 said she had no idea why V4 downloaded her staffing app onto R2's phone. V1 stated, It's completely inappropriate. We have computers and phones at the facility. She could have borrowed a co-worker's phone. She shouldn't have used the phone PERIOD, EVER. V1 said she it's clear that R2 doesn't understand how much personal information is contained in cell phones now. V1 stated, That was the daughter's concern too. The surveyor asked if she knew V4 had attempted to access cash apps on R2's phone. V1 replied, I did not know that. In hindsight, I should have substantiated (misappropriation). The facility's Abuse, Prevention and Prohibition Policy revised 1/2024 showed, Statement of Intent: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse to anyone, including, but no limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, or legal guardians, friends, or other individuals. Policy: The facility prohibits mistreatment, neglect, or abuse of residents . The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect . Definitions: .Misappropriation of Resident Property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent .

Based on observation, interview, and record review the facility failed to ensure a resident's urinary catheter was changed when is was dirty and clogged. The facility failed to keep the catheter drainage bag below the level of the bladder and off the bed for 2 of 3 residents (R1, R3) reviewed for catheters in the sample of 3. Findings include: 1. R1's Face Sheet dated 12/10/24 showed he was admitted to the facility on [DATE] and had diagnoses including cerebral infarction, left hand contracture, pressure ulcer, type 2 diabetes mellitus, severe protein calorie malnutrition, hyperlipidemia, obstructive sleep apnea, spastic hemiplegia of the left side, hypertension, atrial fibrillation, aphasia, left sided hemiplegia, dysphagia, obstructive and reflux uropathy, and gastrostomy. The Physician Orders dated 12/10/24 showed, urinary catheter 16 French, 10 ml (milliliter). Change indwelling urinary catheter as needed for blockage or dislodgement. Change catheter drainage bag as needed for leaking. The Treatment Administration Records dated April 2024, May 2024, June 2024, July 2024, August 2024, September 2024, October 2024, November 2024, and December 2024 did not show that the indwelling urinary catheter was changed. The Progress Notes from 4/3/24 through 12/5/24 did not show that R1's indwelling urinary catheter was changed. R1's Care Plan dated 9/12/24 showed, R1 has a catheter: obstructive and reflux uropathy. R1 will show no signs/symptoms of urinary infection through review date. Catheter care every shift and as needed. Monitor/report to medical doctor for signs of UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urgency/frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. On 12/5/24 the Nurse's Notes for R1 showed, at the ambulance arrived at just before 1:00 AM to transport R1 to the hospital for shortness of breath and audible gurgling. At 3:23 AM, the nurse called the emergency room to check on R1's status, spoke with the ER (emergency room ) doctor who stated R1 was being admitted for sepsis possible related to the indwelling urinary catheter. The hospital ER Nurse's Note dated 12/5/24 at 2:30 AM for R1 showed, patient came in with indwelling urinary catheter from the nursing home; tubing clogged with sediment and stained orange. The catheter tip was corroded in sediment. Indwelling urinary catheter replaced with a new catheter per ER doctor. The ER Physician's Note showed, ED (Emergency Department) Course as of 12/5/24 6:03 AM: 2:52 AM - Indwelling catheter tubing appears to have a lot of sediment and no active drainage upon arrival to the emergency room . After removal of the indwelling urinary catheter, patient had a large amount of bloody urine draining spontaneously, followed by several blood clots, new catheter was placed and patient continued to drain another 400 cc of cloudy fluid, followed by milky thick urine. Gross hematuria spontaneously improved. At 3:23 AM - I spoke with the nursing home nurse .who reports she noticed the patient having trouble breathing and gurgling respirations around midnight Unknown when last catheter was changed. On 12/10/24 at 1:00 PM, V2 DON (Director of Nursing) reviewed R1's ER Nurse's Note and stated she was not aware of any problem with R1's catheter. V2 stated if the catheter tubing was leaking or looked old, had built up secretions, or wasn't draining properly the catheter should have been changed. V2 stated staff should be monitoring the catheter and if it looks bad it should be changed. V2 stated it was not typical to not change a catheter in an 8-month time. V2 stated when a catheter is changed it should be documented on the TAR (Treatment Administration Record). On 12/10/24 at 1:46 PM, V7 RN (Registered Nurse) stated she charts by exception. V7 stated when assessing a catheter, she starts distally to see where the drainage bag is placed; it should be off the floor. V7 stated she looks at the out put of urine as well as the color and consistency of the urine. V7 stated she looks at the insertion site to see if there is any drainage or leaking. V7 stated she changes a catheter if she notices the urine is cloudy, if there is any blood present or if the resident has pain. V7 stated she documents any placement of a catheter or catheter change in the progress notes. V7 stated as far as she new a resident should have catheter changes every 4 or 6 weeks or a rationale as to why the catheter should not be changed. V7 stated not changing a catheter for a long period of time would not be best practice. V7 stated the facility has admission orders; at that time the parameters for catheters and when they are changed should be entered. On 12/10/24 at 5:18 PM, V6 RN stated R1 was her patient in the ER. V6 stated R1 had a catheter in place that looked horrible. The tubing was stained orange. V6 stated she had never seen anything like it. V6 stated the catheter was clogged and not draining so they removed the catheter. The catheter tip appeared corroded and there was blood present. V6 stated R1's urine had a foul odor. V6 stated when they placed the new catheter there wasn't any blood in the drainage bag but there was pus, and the urine was cloudy. V6 stated R1 had a urinary tract infection. V6 stated the ER physician called the nursing home, spoke with the nurse and she did not know when the last time R1's catheter had been changed. The facility's Infection Prevention and Control Manual Resident care - Prevention of Catheter-Associated Urinary Tract Infections policy (2019) showed changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. If an obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter. 2. The Face Sheet dated 12/10/24 for R3 showed diagnoses including chronic obstructive pulmonary disease, retention of urine, chronic respiratory failure with hypoxia, obstructive and reflux uropathy, venous insufficiency, congestive heart failure, peripheral vascular disease, type 2 diabetes mellitua, asthma, obstructive sleep apnea, hypertension, hyperlipidemia, neuropathy, edema, and atrial fibrillation. The Care Plan dated 11/29/24 for R3 showed, R3 has a catheter due to obstructive uropathy. R3 will show no signs/symptoms of urinary infection through the next review date. Catheter care every shift and as needed. Position catheter bag and tubing below the level of the bladder and away from the entrance room door. Monitor/report to medical doctor for signs of UTI (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urgency/frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. On 12/10/24 at 11:32 AM, V5 CNA (Certified Nursing Assistant) and V4 CNA were at R3's bedside to provide bowel incontinence care and catheter care. V4 and V5 had gowns and gloves on. R3 was laying in bed on her back with her catheter drainage bag in a bag holder on the lower side of the bed. R3's catheter tubing showed cloudy urine with sediment present. V4 used disposable wipes to clean the stool off from R3's groin and vagina. V4 changed her gloves, used a disposable wipe and cleaned the catheter tubing from the urinary meatus and away from the resident. V5 took the drainage bag and handed across the bed, holding it at her chest level and above the resident's bladder when giving the drainage bag to V4. R3 stated, keep the bag down otherwise the urine is going to go back down the tube, and I will get an infection. It also hurts when it (urine) goes backwards. V4 and V5 nodded yes and then stated R3 was a retired nurse. R3 was turned onto her side and V4 cleaned her buttocks with disposable wipes. V4 picked the drainage bag up and sat it on the end of the bed. V5 picked the drainage bag up from the bed and placed it on the lower side of the bed. V5 picked the drainage bag up and emptied 2300 ml of urine from the bag. V4 and V5 stated the drainage bag should not be above the resident's bladder because urine can flow back and cause an infection. V4 and V5 stated the drainage bag should not go on the bed for infection reasons. On 12/10/24 V2 DON (Director of Nursing) stated the drainage bag should always be kept below the level of the bladder. V2 stated the drainage bag should not be on the bed due to infection control. The facility's Infection Prevention and Control Manual Resident care - Prevention of Catheter-Associated Urinary Tract Infections policy (2019) showed, keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

Based on observation, interview, and record review the facility failed to develop a comprehensive care plan that provided interventions for a resident's known behaviors for 1 of 9 residents (R2) reviewed for Care Plans in the sample of 9. Findings include: R2's Careplan printed on 11/25/24 did not address R2's behavior of requesting staff to buy things for her or provide interventions for staff to implement when the behaviors are present. On 11/25/24 at 9:45AM, R2 said, I use to have a CNA-Certified Nursing Assistant that would buy things from an on-line retailer for me. We both eventually got in trouble for it. I have a history of having problems with handling money. On 11/27/24 at 9:35AM, V3 CNA said, R2 requested I buy her something. I told her I could not. R2 insisted and gave me the money. I intended to give it back later in my shift. I got busy and forgot. I gave it back to her when I returned the next day. I was not informed R2's behavior of continually requesting staff to buy things for her. On 11/25/24 at 9:54 AM, V1 Administrator said, I dispense the funds for the residents. R2 gets $60.00 per month. R2 will usually take the entire amount out of her account in one lump sum. R2 does ask staff to go to the store for her. On 11/27/24 at 9:09AM, V1 Administrator said, V3 CNA is new to the facility. The more experienced CNA's know how to defer requests to management or activities. There are staff that can purchase items for the residents, the CNA is not appropriate to perform that task. R2's Abuse Investigation dated 11/14/2024 shows, on 11/14/2024 R2 approached a staff member stating she gave a CNA money to buy her snacks. She couldn't remember who, but the CNA did not bring her the snacks. R2 described the CNA. Her description matched two CNAs. Both CNAs were interviewed. V3 (CNA) stated R2 insisted she take the money to buy snacks. Staff member was educated on not accepting money from residents despite their insistence.

Based on observation, interview and record review the facility failed to ensure 1 of 4 residents (R8) was free from verbal and mental abuse when a staff member repeatedly told R8 that his genitalia was tiny and escalated to saying R8's genitalia is useless and should just be cut off. This verbal assault resulted in R8 feeling very hurt, angry, feeling pain, and significant distress from the verbal abuse. This failure applies to 1 of 4 residents (R8) reviewed for mental abuse in the sample of 14. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/7/24 when R8 notified V2 (Director of Nursing) and V1 (Administrator) that V10 (Certified Nursing Assistant- CNA) repeatedly told R8 that his genitalia was tiny and escalated to V10 saying R8's genitalia is useless and should just be cut off. V15 (Assistant Administrator) and V17 (Regional [NAME] President) were notified of the Immediate Jeopardy on 11/14/24 at 8:14 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on 11/11/24, prior to the start of the survey and was therefore Past Noncompliance. This Past Noncompliance occurred from 11/7/24 to 11/11/24. Findings include: R8's Face Sheet dated 11/13/24 shows R8 has diagnoses that include spina bifida, suicidal ideations, bipolar disorder, major depressive disorder, and anxiety disorder. R8's Minimum Data Set assessment dated 9/l1/24 shows R8's Brief Interview for Mental Status (BIMS) results were 14 out of 15, indicating R8 it cognitively intact. On 11/13/24 at 8:58 AM, V1 (Administrator) said V10 (CNA) was immediately suspended on 11/7/24 and an initial investigation into the incident was started. V10 was later terminated on 11/12/24 for the remarks that were made towards R8. On 11/13/24 at 9:10 AM, R8 said that R8 and V10 (CNA) initially had a good relationship. After some time of V10 working with R8, R8 said V10 would constantly find the need to make fun of R8's anatomy and verbally assault him. R8 said the names were very hurtful and he would get angry at V10 and yell at him to shut up, get out of my face, and I (R8) don't ever want to see you again. R8 said there were even times that R8 would get so angry, he wanted to physically strike V10 in the face so V10 could feel a fraction of the pain that V10 had put R8 through. R8 mentioned that R8 would dread the 2:00 PM shift change, knowing that was when V10 typically worked with R8. R8 could not definitively say how long V10 was saying these things to R8 but knew it was going on for multiple months. R8 never told anybody about the incidents in fear that V10 would lose his job. R8 did not want to be responsible for V10 losing his job knowing V10 recently had a baby. R8 ended the interview with R8 wiping away a tear from R8's left eye stating, I would like to be done talking about the incident. On 11/13/24 at 9:26 AM, V9 (Former CNA) said a few months ago, V9 overheard R8 calling V10 stretch because V10 is tall and V10 responded calling R8 tiny. V9 called V10 out of the room and questioned why V10 called R8 tiny. V10 responded saying it was in reference to R8's penis size. V9 told V10 that is considered sexual abuse and he should not be saying that. V10 responded to V9 saying, I don't care at first and later said, okay, okay, I'll stop. On 11/13/24 at 10:30 AM, V1 (Administrator) said R8 confided in V1 stating that V10 would call his penis tiny. R8 stated the comments were escalating recently to where V10 would tell R8 that his genitalia was useless and should just be cut off. On 11/13/24 at 11:45 AM, V2 (Director of Nursing) said R8 approached her on 11/7/24 to talk to her about an issue R8 was having. R8 began the conversation stating that R8 was not very blessed in the male genitalia area and V10 calls him tiny. R8 stated he used to try and laugh it off but R8 now gets really mad about the comments from V10. R8 told V2 that V10 makes fun of R8 until R8 gets mad at V10 and begins yelling and screaming at V10. R8 also told V2, DON that sometimes V10 makes fun of (R8's) disability. V2 said this was the first time R8 had brought this to V2's attention. The facility provided Investigative Summary dated 11/11/24 states, . [R8] said he (R8) initially tried not to let it bother him (R8), but it had been ongoing for several months and had caused him (R8) significant distress, while he (R8) often tried to laugh it off, he (R8) admitted that these remarks had deeply hurt him (R8). On 11/13/24 at 1:55 PM, V16 (Medical Director) said he spoke with R8 and R8 stated he was very sad and upset about the incident. R8 said it was not a one-time thing and it was a repeated offense. V16 said there is no question that this incident has effected R8's well-being and daily living. V16 said if a staff member were to make fun of a resident's penis it would be considered a form of abuse, especially knowing it has effected his well-being. The facility Abuse, Prevention and Prohibition Policy revised 01/2024 states, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals . When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcome of the facility investigation, prosecution, or disciplinary action against the employee . Definitions: .Mental abuse includes but is not limited to, humiliation, harassment, and threats of punishment or deprivation. Mental abuse includes but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident. The Immediate Jeopardy that began on 11/7/24 was removed and the deficient practice was corrected on 11/11/24 when the facility: -Took immediate action to protect the resident by suspending the staff member's employment on 11/7/24 and then terminating the employee from the facility on 11/12/24. -Provided an in-service for all staff regarding abuse education on 11/8/24. -An Emergency Quality Assurance Performance Improvement meeting was held with the interdisciplinary team and medical director on 11/11/24. -On 11/9/24, the facility conducted twenty-seven interviews of alert and oriented residents with no additional outcomes of abuse. -The facility initiated and is conducting ongoing audits by interviewing five staff members weekly for 60 days to ensure compliance. The facility is also interviewing three residents weekly for the next 60 days to ensure that residents have no concerns with abuse allegations.

Based on interview and record review the facility failed to immediately report staff to resident verbal and mental abuse to the Administrator and local law enforcement for 1 of 4 residents (R8) reviewed for abuse in the sample of 9. Findings include: A facility provided investigation summary completed by V1 (Administrator) shows on 11/7/24, R8 reported to V2 (Director of Nursing/DON) that a former Certified Nursing Assistant (CNA) identified as V10 had been making fun of his genitalia. V10 (CNA) was referring to R8's penis as being tiny and it was useless and should just be cut off. The investigation shows that V9 (former CNA) confirmed that V10 had made fun of R8 calling him tiny and V9 said she had told V10 that this was sexual harassment and he should stop. The investigation shows V9 reported she had thought V10 had stopped doing this to R8. On 11/13/24 at 9:10 AM, R8 said that V10 had been making fun of his penis size but he did not report it to anyone because he did not want R8 to lose his job. On 11/13/24 at 9:26 AM, V9 (CNA) said that she was present in the room months ago when V10 was providing care to R8. She was helping R9 (R8's roommate) at the time and heard V10 calling R8 tiny and she wondered why he was doing that because R8 is not a tiny person. V9 said she called V10 out in the hallway and asked him what he was talking about and V10 said he was joking with R8 about his penis size. V9 said she told V10 he needed to stop and not do that because it was sexual harassment. V10 told her he would stop doing that and they were just joking around. V9 said she reported what V10 had said to R8 within the same hour it happened to her CNA supervisor V11. V9 said she did not ever witness this happen again and R8 never complained about it happening to her. V9 said V1 is the administrator and the abuse coordinator and abuse should be immediately reported to a supervisor who will report it to V1 or report it directly to V1. V9 said looking back she wishes she would have called V1 directly but at the time V1 was new to the facility. On 11/13/24 at 10:00 AM, V11 (CNA scheduler) said it was not reported to her months ago by V9 about V10 making fun of R8. V11 said she was called last week by V2 (DON) and asked to take V10 off the schedule but prior to that she was not aware of any incident occurring involving mental abuse for R8. V11 said after she removed V10 from the schedule last week she got a phone call from V9 asking why V10 was removed from the schedule and she asked if V10 was making fun of R8 calling him tiny. V11 said she immediately told V2 that V9 may know something about the abuse allegation for R8. V11 said any allegations or witness of abuse should be reported to the administrator immediately. V11 said making fun of a residents genitals would be mental abuse. On 11/13/24 at 10:30 AM, V1 (Administrator) said that it was reported to her on 11/7/24 that R8 had made an allegation of abuse to V2 (Director of Nursing/ DON) who reported it to her immediately. She interviewed R8 and he confirmed that V10 had been making fun of his penis for months. V1 said she was never informed of the situation that V9 witnessed between V10 and R8 months ago. The first she was made aware of any incident was last week. V1 said both V9 and V10 have been terminated. V1 said when V9 heard what she thought maybe abuse months ago it should have been reported to her immediately. V1 said staff are trained on hire, and more frequently then on an annual basis about reporting of abuse. V9's employee file shows she was hired at the facility on 3/22/22. Her training profile shows she had computer based abuse training on the following dates: 3/23/22, 5/3/22, 1/4/23, 3/9/23, 12/7/23, 1/2/24, 1/18/24, 2/20/24, 2/22/24, and 5/21/24. The facility provided Abuse, Prevention and Prohibition Policy revised 1/2024 shows employees should immediately report any abuse to the facility administrator or the designated representative in the administrators absence. This policy documents the facility is to report to law enforcement no later than 2 hours after the allegation is made.

Based on interview and record review the facility failed to ensure an alleged physical abuse was immediately reported to the administrator for 1 of 4 residents (R1) reviewed for allegations of abuse in the sample of 4. Findings include: R1's Face Sheet shows that he was admitted to the facility on [DATE]. On 7/18/24 at 1:03 PM, V13 (R1's Family Member) said that about a month ago, R1 called her and said that he fell out of his wheelchair and a (specific race) male Certified Nursing Assistant (CNA) came into his room and reprimanded him and picked him up and pushed him against the wall and he fell again. V13 said that she went to the facility and spoke with the head nurse about the situation. V13 said, I told her exactly what I just told you. V13 said that V2 (Director of Nursing) left the room and came back about 15 minutes later and said that it did not happen. On 7/18/24 at 11:30 AM, R3 (who resides in the room next to R1) said that he heard R1 complaining about V7 (CNA) on 7/4/24. R3 said that he heard R1 yelling don't hit me, don't push me when V7 was in his room. On 7/18/24 at 9:21 AM, V5 (CNA) said that V7 (CNA) came to her about a week ago (verified it was 7/10/24) and asked her to go into the room with him to provide care to R1. V5 said that when she was in the room, R1 stated to her that V7 was evil and had pushed him. On 7/18/24 at 11:13 AM, V7 (CNA) said that on 7/4/24 around 3-4:00 PM, he went into R1's room because he noticed that his legs were hanging off of the bed. V7 said that he fixed his legs and R1 said to him that he hit him. V7 said that he told R1 that he did not hit him and went and told the nurse what had happened. V7 said that the nurse told him to not listen to R1 and to just leave him alone. V7 said that after that incident, he made sure that there was another staff member in the room with him when he went to provide care to R1. On 7/18/24 at 1:35 PM, V14 (Assistant Administrator) said that around 7/4/24, he and V2 (Director of Nursing) went into R1's room and spoke with R1 and V13 (R1's Family Member) about a fall incident. V14 said that initially, R1 told them that he was pushed into the wall by the CNA and fell . V14 said that in the same conversation, V13 said that she doubted that that happened. On 7/18/24 at 2:18 PM, V1 (Administrator) said that she is the abuse coordinator. V1 said that all allegations of abuse should be reported to her immediately even if the staff feel that they are not true. V1 said that if a resident says that a staff member pushed them and they fell , that would be an allegation of physical abuse and should be reported to me immediately and investigated. V1 said that she did hear from V2 and V14 about the fall incident on 7/4/24 but they never told her that R1 was alleging that a staff member pushed him and he fell . The facility's Abuse Prevention and Prohibition Policy revised on 1/24 shows, Resident abuse must be reported immediately to the Administrator. The facility administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action.

Based on observation, interview and record review the facility failed to ensure a resident who is a high risk for falls was supervised and ensure fall interventions were in place. This failure resulted in R6 falling forward out of her wheelchair and hitting her head on the floor. R6 sustained a forehead laceration requiring transport to the hospital and R6 requiring sutures. This applies to 1 of 18 residents (R6) reviewed for safety in the sample of 18. Findings include: R6's face sheet shows R6's diagnoses including unspecified dementia, unspecified psychosis, anxiety, delusional disorders, repeated falls, peripheral vascular disease and hallucinations. R6's Fall Risk assessment dated [DATE] shows she is a HIGH risk for falls. R6's careplan revised on 6/3/24 shows she is a risk for falls, due to weakness, balance problems, dementia, urinary bladder incontinence, psychotropic/opiate medication use and has a history of falls. Interventions include anti-tippers on front of wheelchair's, anti-slip mat under wheelchair cushion, ensure appropriate footwear, low bed, provide reacher/grabber. This careplan shows she has severe impaired mental function with interventions including to engage R6, in simple, structured activities, provide a program of activities, she requires supervision and assistance when interacting with other residents. The facility's Incident Report dated 5/28/24 documents R6 was found lying on her right side, left side of head facing upward on the floor on the (specific floor) television (TV) room. According to another resident (R21) sitting in the room she (R6) fell forward while reaching for something. (R6) had been wheeling herself around the halls post dinner, the CNA was going in and out of other resident rooms . R1 was transferred to the local hospital and returned with sutures to her forehead. On 6/3/24 at 10:26 AM, R6 was observed self-propelling in her wheelchair going up and down the halls. R6 had a dark purple bruise under her left eye, abrasion to the bridge of her nose and sutures to her left forehead. R6 asked this surveyor, can I go this way? 6/4/24 at 8:32 AM, R6 was lying in her bed. A large purple bruise was observed on her left hand, dark purple bruise under left eye and light yellowish bruising to her right forehead. At 10:24 AM, R6's wheelchair was outside of her room with her name. R6's wheelchair had a cushion and did not have an (anti-slip mat) in place. On 6/4/24 at 8:36 AM, R21 said on 5/28/24 he was in the TV room with R6. R6 leaned forward from her wheelchair and hit her head on the floor. He called for help and the staff came. On 6/4/24 at 10:24 AM, V7 (Certified Nursing Assistant) said R6 is alert to self, she yells out, wanders into other resident rooms and takes things out of other resident rooms we try to re-direct her but she does not comprehend and she tries to get up without assistance. We have to keep a close watch on her. On 5/28/24, another family member reported R6 was wandering into her mother's room trying to take her mom's stuff. V7 said she was in another resident's room and heard someone yell for help. R6 was in the TV room on the floor with her wheelchair tipped over. R21 was in the room with R6 when it happened he said she was bending down reaching for something. On 6/5/24 at 4:20 PM, V8 (CNA) said on 5/28/24 she was R6's CNA. That day R6 was more confused, she was talking to the walls, she was strolling her in the wheelchair and spent a lot of time with her. V8 said R6 was bending forward out of her wheelchair several times prior to her fall that day, but did not know why. She placed R6 in front the nurses station and left to assist another resident. Later she heard someone yell out for help. R6 was on the floor bleeding with the wheelchair flipped over in the TV room on the 200 hall. R21 was in the room with her and called out for help. She said R6's wheelchair had only a cushion. When asked if R6 had an anti-slip mat, V8 replied What's that? She only had a cushion, R6 had dementia, is impulsive and needs to be supervised. On 6/5/24 at 9:04 AM, V2 (DON) said she's been at the facility for about two months. On 5/28/24 she was notified of R6's fall. On 5/28/24, R6 was in the dining room/TV room on the (specific location in facility) with R21. R21 said R6 was reaching down to pick something up and fiddling with her shoe. R6 fell forward and hit her head on the floor. She was bleeding and was sent out to the local hospital and received sutures to her forehead. R6's wheelchair should have anti-tippers and an anti-slip mat on top of her cushion to prevent her from falling out of her wheelchair. In the evening after dinner we try to keep her occupied because she has some sundowning. R6 has dementia and we are looking for placement to get her into a memory care unit. At 10:35 AM, V2 confirmed R6's wheelchair did not have an anti-slip mat to her wheelchair cushion. The anti-slip mats were locked up in the storage room. The facility's Falls Policy revised 9/2019, states, The purpose of the Fall Management Program is to develop, implement, monitor and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life .residents found to be at high risk for falls are placed on the Fall Program, and Interventions are implemented to meet individual needs .

Based on interview and record review the facility failed to ensure monthly dietary assessments were completed for a resident on a feeding tube (R55) and for a resident with non- pressure wounds with a history of significant weight loss (R17) and failed to notify the Dietician of continued significant weight loss for a resident (R17). These failures contributed to a delay in implementing additional dietary interventions for R17 following a significant weight loss of 9.09% in 2 months. This applies to 2 of 12 residents (R17, R55) reviewed for weight loss in the sample of 17. The findings include: 1. R17's face sheet shows she has diagnoses including: Unspecified Dementia, Major Depression, Type 2 Diabetes, and anxiety disorder. R17's weight trending history is as follows: On 7/29/22, R17 weighed 248.1 lbs. On 7/5/23, R17 weighed 165.2 pounds which is an overall 33.41 % -82.9-pound (lb.) loss in 1 year. On 1/15/23, R17 weighed 204.6 lbs. On 7/5/23, R17 weighed 165.2 pounds which is a 19.26 % -39.4 lb. loss in 6 months. On 4/1/23, R17 weighed 193.6 lbs. On 5/30/23, R17 weighed 176.0 pounds which is a 9.09 % -17.6 lb. loss in 2 months. On 6/3/23, R17 weighed 176.0 lbs. On 7/5/23, R17 weighed 165.2 pounds which is an additional 6.14 % -10.8 lb. loss in 1 month. R17's dietary notes and assessments show she was seen by dietary, and an assessment was completed on 4/13/23. That dietary assessment refers to R17 having pudding and ice cream as current supplements and having wounds (necrotic toes to her right foot). R17 was next seen by dietary for an assessment on 5/18/23 (no May weight for R17 had been recorded at that time) and there were no additional dietary interventions implemented or added. R17's nursing progress notes show she had a change in condition and went to the hospital on 5/26/23 for a medical condition and returned on 5/30/23. No dietary assessment was completed upon R17's change in condition (hospital return). R17 had a significant weight loss occur from 4/1/23 to 5/30/23 of 9.09%. R17 had an additional significant weight loss from 5/30/23 to 7/5/23 of 6.14%. The next dietary assessment for R17 was not completed until 7/12/23 (43 days after her change in condition) at that time health shakes 2 times a day were added for nutritional support. There were no documented dietary assessments for R17 from 5/18/23 until 7/12/23. R17's nursing progress notes show R17 continues to have wounds on the toes of her right foot as of 7/19/23. On 7/17/23 at 11:42 AM, V17 (R17's son) said he has not had a dietary person come and talk to him in quite some time and has concerns with R17's weight loss. V17 said he comes to the facility daily and R17 will eat when she is encouraged and its foods she likes. On 7/19/23 at 9:12 AM, V9 (Regional Operations Manager/Registered Dietitian) said residents who are considered high risk for weight loss should be seen and have a dietary assessment monthly. V9 said she cannot dispute that high-risk residents would include R17 since she has significant weight loss and wounds to her toes and should have been seen monthly. V9 said she cannot speak for V15 (Registered Dietitian) whether she was notified of R17's continued weight loss and hospitalization . V9 additionally said V15 had fallen behind on some of her assessments at this facility so other Dietitians were assisting her. V15 was attempted to be contacted by this surveyor on 7/19/23 and no return call was received from her. On 7/19/23 at 10:42 AM, V2 (Director of Nursing) said the facility protocol is that residents should be seen by dietary monthly and more often if needed for assessments following hospitalization , significant weight loss, and if they are high risk with tube feedings or have wounds. V2 was unable to determine if anyone notified V15 (Registered Dietitian) following R17's hospital return and continued significant weight loss. V2 said the person who was informing the Dietitian of these issues was her former wound nurse who no longer works at the facility. V2 verified R17 should have been seen prior to 7/12/23 for additional dietary interventions to be implemented. The facility-provided Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol policy (revised September 2012) states, The threshold for significant unplanned and undesired weight loss will be based on the following criteria a. 1 month- 5% weight loss is significant; greater than 5% is severe. b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe, c. 6 months- 10% weight loss is significant; greater than 10% is severe. Treatment/ Management Supplementation: Strategies to increase a resident's intake of nutrients and calories may include fortification of foods, increasing portions sizes at mealtimes, and providing between-meal snacks and/or nutritional supplementation. 47552 2. R55's Care Plan focus initiated on 12/7/22 states, (R55) Requires Enteral Feedings via Peg Tube due to Dysphagia, and Adequate Nutrition/Hydration. R55's Order Summary Report dated 7/19/23 states, Enteral Feed Order every shift for Nutrition Set Continuous feed of (brand name of enteral feeding) at 50ml/hr (hour) with a start date of 7/4/23. On 4/16/23 at 5:29 PM, V9 (Regional Operations Manager/Registered Dietitian) wrote a dietary note for R55 for an RD Wt (Registered Dietitian Weight)/Tube Feeding Review . On 7/11/23 at 2:34 PM, V15 (Registered Dietitian) completed a Dietitian Nutrition Assessment for R55. R55 did not have a tube feeding assessment completed for May or June. On 7/18/23 at 2:24 PM, V9 (Regional Operations Manager/Registered Dietitian) said monthly dietitian progress notes should be completed for high-risk residents, including those receiving a tube feeding. V9 also said the facility was provided dietitian coverage on 5/4/23, 5/18/23, 6/14/23, and 6/27/23.

Based on interview and record review the facility failed to ensure a resident was safely assisted to re-position in bed. This failure contributed to (R17) sustaining abrasions to her toes which became gangrene requiring wound care, hospitalization , and recommended amputation to her right toes. This applies to 1 of 7 residents reviewed for safety in the sample of 17. The findings include: On 7/17/23 at 9:56 AM, R17 was in her bed. From the doorway R17's right foot was visible. Her great toe and the next 3 toes were observed to be black in color. R17 was attempted to be interviewed but was cognitively impaired and could only ask the surveyor to please be careful and not touch her toes. On 7/17/23 at 11:30 AM, V17 (R17's son) said his mom R17 has had the wound to her toes for quite some time possible back to March 2023. V17 said the facility never gave him an explanation of how these (traumatic) wounds started but he knows they started out as scrapes with scabs on them and have progressed to now requiring a vascular surgeon and amputation has been discussed. R17 said his mom does not get up out of bed so he cannot understand how these traumatic wounds could have happened. On 7/18/23 at 1:03 PM, V8 (Wound Nurse) said R17's toe wounds started out as scabbed areas following an incident where she was walking down the hallway and heard R17 calling out for help. V8 went into R17's room and saw her sitting on the edge of the bed with her legs straight out in front of her. She said she called out for other staff to help, but she was in the alone in the room and picked up R17 legs to swing them onto the bed. As she did so, R17's foot scraped against a vent that was on the wall causing abrasions to her toes. V8 said she did not document the incident, but she believes it was the beginning of April. V8 did tell the facility's former wound nurse and the nurse who was assigned to R17 that day. V8 said R17's toes have just continued to progress to the point where they are currently gangrene and she is going to see a vascular surgeon. V8 said the current wound physician (V19) who is treating R17 has discussed amputation of her toes. On 7/18/23 at 1:51 PM V19 (Wound Care Physician) said he believes R17 has some evidence of peripheral vascular disease, but her toe wounds started as a result of trauma. V19 said the incident where her toes were scraped on the wall is what contributed to this condition manifesting. V19 said it is possible without this incident her toes would not be in the condition they are in now. V19 described R17's toes as dry gangrene and he has referred her to a vascular surgeon to discuss what level of amputation would be appropriate for this resident based on her age and overall health status. V19 said R17 has had scans to her lower legs that do not indicate arterial insufficiency, but he feels the reports are contradicting and she has arterial insufficiency. R17's face sheet shows she has diagnoses including Unspecified Dementia, Type 2 Diabetes without complications, hypertension, and Peripheral Vascular Disease (this diagnosis was added on 7/18/23). R17's quarterly assessments completed 4/6/23 and 4/14/23 show R17 has a cognitive deficit with a memory impairment, and she requires extensive 2 person staff assistance with bed mobility and re-positioning. R17's nursing progress notes do not show documentation of the incident where R17's toes were scraped on the wall vent during re-positioning. R17's electronic medical record has hospital records for R17 dated 3/19/23-3/22/23, which show an abrasion present to R17's 2-4th toes. The wound beds are described as scabs, clean and dry with some redness. A patient scan report completed on 4/17/23 shows R17 had a right Doppler scan to her lower extremities and the report states, No hemodynamically significant stenosis [narrowing of the arteries]. R17's wound care notes and assessments completed by V19 show the following progression of R17's toe wounds: 3/30/23- Right foot toe wounds from trauma to the 3rd, 4th and 5th toes, no drainage and 100% eschar (necrotic) tissue present. 4/6/23- Right foot toe wounds remain the same with 100% eschar tissue to the 3rd, 4th, and 5th toes. 5/31/23- Progressive ischemia to right hallux (big toe) At this point would be reasonable to refer to podiatry for digit amputation. 6/14/23- right toe wounds now identified as the 2nd, 4th and 5th toes show the wound bed to be mummified (dried up and dehydrated) and auto amputation at the hallux. 7/12/23- continue to wait son's decision but agreeable to vascular consultation. A health status note completed for R17 on 6/19/23 by V8 states, wound doctor suggesting amputation. On 7/19/23 at 8:03 AM (V2) Director of Nursing said she called V20 (Medical Director) last evening (7/18/23) to come and look at R17's toes. V2 said the decision was made to send R17 to the hospital because V20 felt that there may be some wet gangrene and redness (possible infection) to her right foot. V2 said R17 was admitted to the hospital but she did not have an update at that time.

Based on observation, interview, and record review the facility failed to implement interventions to prevent pressure ulcers, failed to identify pressure injuries, and failed to accurately assess pressure injuries for a resident at risk for developing pressure ulcers for 1 of 3 residents (R1) in the sample of 4. These failures resulted in R1 developing a pressure ulcer to his sacrum which the facility assessed as a stage 3 on 1/1/23, corrected staging on 1/3/23 to a stage 2, and was assessed by the acute care hospital wound care nurse on 1/3/23 as an unstageable pressure injury with areas of eschar and slough. The facility failed to identify wounds to R1's bilateral heels which were identified at the acute care hospital during upon admission on 12/11/22 and again on readmission to the acute care hospital on 1/3/23. The findings include: R1's medical record showed he was admitted to the facility on [DATE] with diagnoses to include disorders of electrolyte and fluid balance, muscle weakness, unsteadiness on feet, cognitive communication deficit, apraxia (neurological movement disorder), and dementia. R1's facility assessment dated [DATE] showed he has severe cognitive impairment and requires extensive to total assist for all activities of daily living. R1's pressure risk assessment complete 11/11/22 showed he was at risk for developing pressure ulcers. On 1/11/23 at 1:54 PM, V12 (R1's Daughter) said she was at the facility visiting her father on 1/3/23 when she saw a tube of cream on his bedside table. V12 said there was a CNA (Certified Nursing Assistant) in the room at the time and she asked what the cream was for. V12 said the CNA responded saying, He has bedsores, didn't they tell you? V12 said she met with the DON (Director of Nursing) on that same day and the DON told her she was not aware of [R1] having bedsores until that conversation with V12. R1's complete care plan was reviewed with no evidence of a care plan initiated for pressure prevention measures. R1's acute care hospital documents from his 12/11/22 through 12/13/22 hospital stay showed R1 was admitted to the hospital on 12/11/22 with a pressure ulcer to his sacrum, left heel, and right heel. R1's eTAR (electronic Treatment Administration Record) for December 2022 showed no dressing changes to any pressure wounds to R1's bilateral heels or sacrum. R1's January 2023 eTAR showed no treatments to R1's bilateral heels and a new treatment started for a pressure injury to R1's sacrum on 1/2/23. R1's nursing note dated 1/1/23 at 11:50 PM showed, Coccyx pressure, Stage 3; Cleanse with wound cleanser, skin prep peri-wound. Apply Calcium alginate to wound bed. Cover with large bordered gauze. R1's 1/3/23 (the day the wound was identified) Daily Skilled Note showed, Skin Condition . NONE. R1's 1/3/23 (the day the wound was identified) Skin Check Assessment showed, no new changes this week. R1's 1/3/23 Skin & Wound Evaluation showed a new pressure ulcer measuring 3.9 cm x 6.0 cm with a moderate amount of serosanguineous drainage was present. R1's medical record showed he was readmitted to the acute care hospital on 1/3/23. R1's acute care hospital documentation dated 1/3/23 showed R1 had pressure wounds to his sacrum, right heel, and left heel on admission. R1's acute care hospital, wound care consult, dated 1/4/23 showed R1 had a deep tissue injury to his right heel measuring 3 cm x 2.6 cm, a stage 1 pressure injury to his left heel measuring 3 cm x 5 cm, and an unstageable pressure wound to his sacrum measuring 6.5 cm x 8.5 cm x 0.1 with areas of eschar and slough. R1's nursing note dated 1/3/23 at 12:23 PM and entered by V5 (Wound Care Nurse) showed, Correction to staging - this is a stage 2 pressure/coccyx per WCN (Wound Care Nurse) assessment. Peri-wound is pink, no edema noted. Wound bed is pink, moderate serosanguinous drainage. Cleansed with wound cleanser, pat dry. No obvious signs or symptoms of tenderness noted. Skin prep to periwound. Applied calcium alginate to wound bed. Covered with bordered gauze dressing. Updated floor nurse. On 1/12/23 at 1:20 PM, V5 (Wound Care Nurse) said skin checks are done weekly. If the nurse finds a new skin condition they would measure it, sent the information to the provider, enter a treatment order, and enter the new skin condition into the facility's risk management system. V5 said the nurse would also be expected to notify the family of the new area. V5 said R1's skin conditions consisted of lacerations with sutures and then recently a new pressure ulcer to his sacrum. V5 said she started the low air loss mattress for prevention at the time the order was entered into the electronic medical record after the wound was identified. V5 said other pressure prevention interventions were frequent checks for incontinence and frequent repositioning. V5 said she is not sure if R1 needed anything more for pressure prevention because it was a surprise to them when they identified the wound. V5 said the pressure ulcer is unfortunately facility acquired and likely caused by the resident being stiff while turning side to side, gravitating back to a supine position, and not quite enough effort by staff with turning and repositioning. V5 said she was not aware R1 had pressure injuries to both of his heels. V5 said she did not notify the power of attorney regarding R1's pressure injury. On 1/12/23 at 4:30 PM, V2 (Director of Nursing/DON) said she was not aware R1 had any pressure ulcers until 1/3/23 when she was approached by V12 (R1's daughter) when he was having a change of condition and being sent to the hospital for evaluation. V2 said on admission and readmission a skin assessment is done to identify current skin conditions and determine risk for pressure ulcers. V2 said R1 should have a care plan in place for pressure prevention. V2 said she would expect nursing staff to identify new skin conditions when they appear as redness to the skin because they should be doing skin checks every time they do incontinence care and when they give showers. V2 said it is important to put interventions in place prior to wounds developing into advanced stages. V2 said she would expect to be notified of new skin conditions and would expect the power of attorney to be notified of new skin conditions. V2 said notifying the family regarding new treatments and conditions is part of providing caring for the resident. The facility's policy with revision date March 2022 titled Pressure Ulcer/Pressure Injury Prevention showed, . A facility must: Identify whether the resident is at risk for developing or has a pressure ulcer/pressure injury upon admission and thereafter; Evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a pressure ulcer/pressure injury; Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors; . The first step in prevention of pressure ulcers/pressure injuries is the identification of the resident at risk for developing pressure ulcers/pressure injuries. This is followed by the implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions. An individual plan of prevention will be developed to meet the needs of the resident. It will include the consideration of mechanical support surfaces, nutrition, hydration, positioning, mobility, continence, skin condition and overall clinical condition of the resident as well as the risk factors as they apply to each individual . Based on evaluation, the need for reassessment and further changes to the individual resident's plan of care will be determined and acted upon.

Based on observation, interview, and record review the facility failed to implement fall precaution interventions to prevent falls for 2 of 3 residents (R1, R3) reviewed for falls in the sample of 4. This failure resulted in R3 experiencing 5 falls between 11/26/22 and 1/11/23 requiring R3 to be transferred to the acute care hospital for evaluation each time. The findings include: 1. R3's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include aphasia, anemia, major depressive disorder, anxiety disorder, hydrocephalus, gastrointestinal hemorrhage, and cutaneous abscess of abdominal wall. R3's facility assessment dated [DATE] showed he has short term memory problems, severely impaired decision-making processes, and requires extensive assist with activities of daily living. The facility's fall log for the previous 3 months showed R3 had fallen on 11/28/22 and 1/11/23. R3's medical record showed he had also experienced falls on 11/26/22, 11/29/22, and 12/12/22. R3's records showed he fell from his wheelchair on 11/26/22, 11/28/22, 12/12/22, and 1/11/23. R3's nursing note dated 11/26/22 at 11:39 AM showed, Resident received crying and inconsolable. Night nurse administered valium at 6:39 AM. He is sad and wants to speak with family members attempted to call all the numbers listed by the resident's wall . Asked the CNA to get up the resident for mealtime and so his mood will brighten up. Will give Valium when it is due at 2:39 PM . R3's nursing note dated 11/26/22 at 5:04 PM showed, . Writer went to the nurse station to report the incident to [R3's Physician or Nurse Practitioner] . as soon as writer sat, CNA called me and said resident was unresponsive, went immediately to patient's room and saw another CNA doing chest rub, resident with pulse and breathing. I immediately called 911 and emergency cart brought to the resident's room Resident was in and out of consciousness unable to do blood pressure due to resident's movement . R3's SBAR Communication Form dated 11/26/22 at 3:30 PM showed, At around 2:40 PM, writer was in break room when another nurse came and told me the resident was on the floor. Went immediately to the patient's room and observed him laying on the floor by the bed. He was crying. He's been sad the entire shift. Asked if he hit his head on the floor, he was just saying ok and crying . fall is unwitnessed. Resident was assisted back to the wheelchair . R3's nursing note dated 11/28/22 showed, . The resident is experiencing a change in condition . Resident had an unwitnessed fall at 1:00 PM in the dining room. Noted resident on his right side on the floor in dining room, no bleeding or bruises noted. Resident was assisted back to his wheelchair and brought him in his room on the bed Resident was sad and crying this morning . R3's care plan initiated 11/28/22 showed, [R3] is at risk for falls related to deconditioning, gait/balance problems, foley catheter, psychoactive medication use, and traumatic brain injury .Intervention added on 12/1/22, adjust seat wheelchair for positioning aide for forward and side slumping. R3's 11/28/22 fall risk data collection sheet showed R3 is a high risk for falls. R3's 1/11/23 fall risk data collection showed R3 had an unwitnessed fall in his room on 1/11/23. R3's acute care hospital documentation dated 11/30/22 showed, Chief Complaint, Unwitnessed fall . History obtained from patient's daughter who states patient is unable to verbalize his symptoms at baseline. She reports three falls this week, first one occurred on Saturday where patient fell out of wheelchair, another fall from wheelchair on Sunday, and today had a fall from bed . R3's acute care hospital After Visit Summary dated 12/12/22 showed, . Reason for Visit, Fall, Diagnoses: Head injury, fall from wheelchair, history of traumatic brain injury . Instructions: . Consider increasing supervision levels while in wheelchair due to frequent falls. Monitor patient closely while he is up sitting in wheelchair - especially while giving any sedative medications to help prevent future falls . R3's nursing note dated 1/11/23 at 10:46 AM showed, Resident very anxious, (anxiety pill) offered, this resident covered his mouth and got very angry and kept saying okay and no okay . Attempted to give medications again and he kept shaking his head and covered his mouth again. Placed medication down on the counter at the nurses station and this resident pushed the medication off the counter, resident angry also about foot pedals. This RN (Registered Nurse) attempted to change foot pedals and still angry. R3's nursing note dated 1/11/23 at 2:54 PM showed, The resident is experiencing a change in condition fell out of chair onto his right side and the right side of his head has a bump and he is hard to arouse . He has been anxious/agitated all day refusing to take his medications, refused to go to bed after breakfast and slept on the nurses station. Resident went to lunch in the main dining room and was returned to his room for a short while until he could be placed into bed. This resident fell on the floor unwitnessed and appears to have hit his head on the right side where his shunt is. resident was placed into bed and was arousable and crying at that time. Neuro checks started after he was placed into bed and became very lethargic and arousable by sternal rubs and loud noises. Eyes rolled into head when light was shined into his eyes, unable to follow commands at this time. R3's nursing note dated 1/11/23 at 10:00 PM showed, Returned from [acute care hospital] in stable condition, daughter at bedside and very upset stating she wants him to have a fall risk bracelet and signs on his door and above his bed . On 1/12/23 at 2:18 PM, V4 (Registered Nurse/RN) said R3 is impulsive and easily agitated. V4 said on 1/11/23 R1 refused to take his medications and pushed them off the counter onto the floor. V4 said on 1/11/23 R1 had been brought back to the unit from the dining room after lunch by the activity aide. V4 said she told the activity aide to put him in his room and they would be in to put him into bed soon. V4 said she felt it was ok to leave him in his room unsupervised because she was going to the bathroom, and he would have been unsupervised at the nursing station as well. V4 said when she came out of the bathroom R3 was noted to be on the floor. V4 said R1 had a lump on his head near his shunt, is on blood thinners, and became lethargic after the fall so they sent him to the emergency room to be evaluated. On 1/12/23 at 4:30 PM, V2 (Director of Nursing/DON) said the reason R3's falls on 11/26/22, 11/29/22, and 12/12/22 were not on the fall log is because they were not entered in the facility's software which is used to track and investigate falls because the system had some kind of glitch. V2 said the other documentation in R3's record regarding those falls would be the investigation. V2 said R3 is and is not safe in his wheelchair unsupervised. V2 said R3 gets easily agitated and when he is agitated, he is unsafe to be left alone. 2. R1's medical record showed he was admitted to the facility on [DATE] with diagnoses to include disorders of electrolyte and fluid balance, muscle weakness, unsteadiness on feet, cognitive communication deficit, apraxia (neurological movement disorder), and dementia. R1's facility assessment dated [DATE] showed he has short and long term memory problems and requires extensive to total assist for all activities of daily living. On 1/11/23 at 1:54 PM, V12 (R1's Daughter) said R1 had a fall on 12/11/22 during which he sustained a broken nose and required 6 sutures. V12 said was not safe to be alone in his room in his wheelchair and he was left in there anyway. V12 said after R1's fall on 12/11/22 the facility got him a new wheelchair that was more reclined so he would not be able to fall out. V12 said she spoke with staff at the facility prior to R1's 12/11/22 fall and told them he is a high risk for falls and cannot be left alone. R1's care plan initiated 11/16/22 showed, [R1] is at risk for falls due to dementia, gait/balance problems, poor communication, apraxia, weakness, and deconditioning . Interventions, Assess clothing for proper fit, Assess for UTI ., Be sure [R1] call light is within reach and encourage the resident to use it for assistance as needed, Ensure personal items are within reach, Ensure that the resident is wearing appropriate non-skid footwear when ambulating or mobilizing wheelchair . The same care plan showed updates added after he was readmitted from the acute care hospital to Apply floor mats to both sides of resident's bed. Apply floor mats to both sides of resident's wheelchair, Dropped seat in wheelchair to facilitate appropriate positioning, Reclining back wheelchair for positioning aide for forward slumping, Resident to lay down after meals and therapy, per POA/family request/wishes. Resident will not be left in the wheelchair after meals and therapy. R1's acute care hospital documentation dated 12/13/22 showed, admitted : 12/11/22 . Chief Complaint, Patient presents with unwitnessed fall from wheelchair at 3:30 this afternoon . laceration to forehead, abrasion and swelling to nose . Alert and oriented to 1 at baseline . Admission Diagnosis: Facial laceration .closed fracture of nasal bone . hematoma of scalp .Fall at nursing home . unwitnessed fall . HPI (History of Present Illness) Patient is an [AGE] year old man with past medical history relevant for hypertension, gout, depression, chronic atrial fibrillation not on anticoagulation, bedridden, severe dysarthria, resident of [nursing facility], currently presenting after being found on the floor History is taken from his daughter at bedside. The patient is unable to walk or get out of the bed on his own, but he sometimes is put in a wheelchair. Apparently, the patient was in wheelchair today but was then found on the floor having an unwitnessed fall with blood coming out of his head and swelling of the nose CT head negative for bleeding but showed nasal bone fracture. He was admitted for observation and possible change in SNF (skilled nursing facility) . Safety Awareness, decreased awareness of need for assistance, decreased awareness of need for safety and impulsive, not aware of deficits . On 1/13/23 at 9:22 AM, V11 (Certified Nursing Assistant/CNA) said she worked that day and responded to R1's fall. V11 said when she started her shift, she had seen R1 in his room in his wheelchair. V11 said she had gone down the hall to another resident's room and on the way back to the nurses station area she saw R1 in his room laying on the floor. V11 said she called the nurses for help, they called 911 and R1 was taken to the hospital. V11 said after R1 left she was talking to someone that comes in to see R1 and they told her he should not be in his wheelchair alone because he tries to get up. V11 said if she would have known about him trying to get up in the past, she would not have let him be left in his room. On 1/12/23 at 11:30 AM, V2 (DON) said R1 had been taken to his room from the dining room and the nurse was informed that he was back. V2 said the facility was not aware of R1's POA's wishes for R1 not to left in his room in his wheelchair unattended. On 1/12/23 at 4:30 PM, V2 said she feels R1 was safe to be in his room unsupervised in his wheelchair. V2 said the staff had parked the wheelchair near R1's bed. V2 said R1 has no trunk control so he leaned forward to lean against the bed and that is how he fell to the floor. V2 said she was not aware R1 would lean out of his chair onto his bed so at that time he was not safe to be in his room in his wheelchair by himself. V2 said after R1's fall they dropped the seat of his wheelchair down so he would be a safer position while in the chair and staff will put fall mats down next to the bed if R1 is in the bed and next to his wheelchair if he is in his wheelchair. The facility's policy with revision date of 9/17/19 titled Fall Policy showed, Purpose: The purpose of the Fall Management Program is to develop, implement, monitor, and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Management Program promotes safety, prevention, and education of both staff and residents. Policy: the facility shall ensure that a fall management program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety . .

Based on interview and record review the facility failed to administer an antipsychotic medication to a resident as ordered. The facility failure resulted in R1 having a return of psychiatric behaviors and which required hospitalization . This applies to one of three residents (R1) in the sample of three. The findings include: The facility face sheets shows R1 to have diagnoses to include metabolic encephalopathy, schizophrenia, bipolar, depression and anxiety. The facility assessment dated [DATE] shows R1 required assistance of one staff for ADL's. The medication administration record (MAR) for 10/2022 shows an order for the antipsychotic medication one tablet every morning and two tablets every evening at bedtime. The MAR dated October 2022 shows R1's antipsychotic medication was not given on 10/9/22 evening dose to 10/13/22. The medication is listed as not available in the nursing progress notes. On 12/8/2022 at 1:45 PM, V3 (Registered Nurse/RN) said he discovered that R1 had not received his antipsychotic medication for at least 3 whole days. V3 said he called the POA and V6 (Nurse Practitioner/NP) right away to report what had happened. V3 said V6 told him she was not familiar with this particular antipsychotic and would have to check with the manufacture to see what the protocol was for this type of situation. V3 said he then called the pharmacy and was told the medication could not be dispensed until the provider completed the proper paperwork. On 12/8/2022 at 12:10 PM, V6 said she was the provider ordering the antipsychotic medication for R1. V6 said she was required by the pharmacy to complete the information on the Rems website (website to track this antipsychotic medication), order the lab work and order the medication refills. V6 said she completed this as she was told. V6 said she was shocked when V3 called her to tell her that R1 had missed so many doses of his antipsychotic medication. V6 said this definitely led to R1 needing to be hospitalized . V6 said if this medication is missed for more than 48 hours, the resident will have to start the medication again at lower doses and work their way back to the correct dosage. On 12/8/2022 at 12:55 PM, V4 (Pharmacist) said this antipsychotic medication requires the provider to complete the Rems website with each refill of the medication. Lab work must be completed prior to the dispensing of the medication each time. V4 said the medication was not dispensed to the facility because this had not taken place for R1. V4 said they were not notified from the facility until 10/13/22 that R1 needed more of the antipsychotic medication. V4 said that since R1 had not received the medication for over 48 hours, R1 would have to restart the medication and work his way back to his original prescribed dose. On 12/8/22 at 3:50PM, V2 (Director of Nursing) said the nurses need to follow-up with any medication as to why that medication is not available. V2 said she was planning to do an in-service on this to prevent medications from not being given due to not being available. The facility communication form and progress note dated 10/20/2022 shows R1 was transferred to the hospital for a change in condition. The form shows R1 refusing to open his mouth, stripping his clothes off and having an increased need for ADL assistance. The form also shows increased confusion and new or worsening behaviors. The question on the form asking the RN what do you think is going on with the resident? was answered, side effects of not being on his medication. The NP progress note dated 10/18/2022 shows nursing staff brought to her attention that R1 had missed at least 3 full days of his antipsychotic medication and is having delusional thoughts and trouble swallowing medications and food. The pharmacy worksheet for this antipsychotic medication shows the pharmacy was notified on 10/13/22 of the need for the medication to be dispensed (4 days after first missed dose). The nursing progress notes for R1 shows on 10/9/22, 10/10/22, 10/11/22 and 10/12/22 the antipsychotic medication was not given as it was not available. The nursing progress note dated 10/12/22 shows an RN called the pharmacy to inquire about the missing medication for R1 (4 days after first missed dose). On 10/12/22 the NP entered a progress note showing R1 had not received his antipsychotic medication since 10/9/22 and would have to have stat labs drawn and his dose would have to be dropped and titrated back to his original dose. The facility policy with a revision date for 4/21 for administration of medications shows if for any reason a physician's order cannot be followed, the physician shall be notified as soon as is reasonable. A notation shall be made on the nurse's progress notes in the patient's clinical record.

Based on observation, interview, and record review, the facility failed to accurately assess a resident at risk for elopement and failed to implement interventions to prevent a resident from eloping. These failures resulted in R1 eloping from the facility and being found two blocks away in 34-degree Fahrenheit (F) weather while crawling across a heavily traveled highway. This applied to one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/20/22 when staff were unable to locate R1 inside the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 11/23/22 at 9:09 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice was corrected on 11/21/22, prior to the start of the survey and was therefore, Past Noncompliance. The findings include: The facility's initial incident report sent to the Illinois Department of Public Health (IDPH) showed R1 went missing on 11/20/22 at approximately 3:45 PM after a physical therapist was unable to locate the resident. The report showed staff called an Elopement Code and started looking for the resident. The report showed local police came to the facility to inform the staff that the resident had been taken to the local acute care hospital emergency department by paramedics the same day. R1's face sheet printed on 11/22/22 showed an admitted [DATE] and diagnoses that included, but were not limited to, laceration of the scalp, anxiety disorder, repeated falls, symptoms, and signs involving cognitive functions and awareness, restless leg syndrome, and polyneuropathy. R1's nursing admission assessment of 11/19/22 showed an unsteady gait and a wheelchair required for mobility. R1's hospital discharge summary, dated 11/19/22, showed he was sent to the local hospital following an unwitnessed fall at home and has been developing issues with cognitive impairment per the wife. The summary showed a scalp laceration that was stapled in the emergency room with five staples. An outpatient neurology evaluation of cognitive impairment was recommended. R1's elopement risk assessment, dated 11/19/22 (facility admission), showed the resident was not cognitively impaired and not independently mobile. On 11/22/22 at 10:30 AM, R1 was seated in a wheelchair in his room. Staff were present and the door was closed. R1 stated he was being held a prisoner against his will. R1 said he wanted to get out of here and nobody will let him go. R1 was able to converse but was confused on details and specifics throughout the interview. R1 said he did walk out the front door a few days ago during rush hour. R1 said he was walking home to see his wife and get his glasses. On 11/22/22 at 1:40 PM, V3 (Licensed Practical Nurse/LPN) stated she was working the day R1 was admitted . V3 said R1 was alert but clearly confused and talked of leaving the facility right away. R1 wandered up and down hallways and was not sure where his room was. R1 would not stay in his room and repeatedly said he was going home. V3 said she was also working the next morning when R1 opened the front door in the lobby and walked out of the facility. V3 said it was between 11:00 AM and 12:00 noon. V3 said she and another staff member had to run out the front door to get R1 back inside. R1 was walking quickly away from the building and refused to come back inside. R1 was pushing away from her and was insistent his wife was on the way to pick him up. V3 said R1 was not wearing a hat or gloves and it was very cold outside. On 11/22/22 at 11:05 AM, V4 (LPN) stated she was working the morning R1 was attempting to walk out the front door alone. V4 said R1 had been walking in a confused manner around her unit earlier in the day. R1 was fully ambulatory and kept pushing his wheelchair from behind, rather than remain seated in it. R1 was forgetful and kept looking at exit doors. R1 repeatedly asked what is outside the doors. V4 said R1 was upset he was not getting any physical therapy and his focus was to get out of the building. V4 said V5 (Physical Therapist) met with R1 later that day to distract him from leaving the facility. V4 said she was notified by V5 after the therapy session that R1 was missing from his room. V4 said she called V1 (Administrator) and V2 (Director of Nurses) to report the missing resident. V4 said she called an elopement code and went to the front lobby area to look for R1. V4 said V6 (Receptionist) stated she saw R1 walk out the front door with two unknown women. V4 said R1 was not stopped or questioned while he exited the facility. On 11/22/22 at 10:37 AM, V5 (Physical Therapist) said that he met with R1 in the afternoon the day R1 went missing. V5 said R1 was able to converse but slipped in and out of cognition. V5 said R1 was able to ambulate alone but required a walker or wheelchair for safety. V5 said he last saw R1 sometime after 2:45 PM when he finished his therapy session. V5 said he realized R1 was not in his room at 3:45 PM and alerted V4 (LPN). On 11/22/22 at 9:30 AM, V1 (Administrator) stated he was notified that R1 was missing from the facility on 11/20/22 in the afternoon. V1 said R1 was last seen by a staff member around 3:10 PM when a CNA (Certified Nurse Aide) helped him in the bathroom. V1 said staff members told him R1 walked out the front door with two unknown female visitors. V1 said the receptionist thought R1 was a visitor and therefore let him leave with the females. V1 said the local police arrived at the facility at around 4:00 PM and reported R1 had been found up the street. Police reported R1 had fallen while crossing a heavily traveled road and a bystander called 911. R1 was taken to the local emergency room . V1 said R1 was wearing a light sweatshirt, jeans, and rubber shoes. On 11/22/22 at 1:55 PM, V6 (Receptionist) said that she saw R1 leave the facility on 11/20/22 without any staff present. V6 said it was between 1:00 PM and 4:00 PM and he was with two females. V6 said she did not ask names or identify who the individuals were. V6 stated the females knew the door code and so V6 thought they must be routine visitors. V6 said R1 did not sign himself out when he walked out. V6 said R1 was using a walker and exited the front door. V6 said R1 was wearing a red, long sleeve shirt, stained pants, and rubber shoes. The website Weather History and Date Archive (wunderground.com) showed the temperature on 11/20/22 was 34 degrees Fahrenheit. The facility is located approximately two blocks north of a heavily traveled main highway and with a heavy wooded area outside the front parking lot. On 11/22/22 at 2:05 PM, V2 (Director of Nurses) stated she was notified on 11/20/22 that R1 was missing from the facility in the afternoon. V2 said R1 had been trying to leave the facility earlier and did get out the front door earlier that morning. V2 said R1 had been a resident in the past (2021) and admitting staff thought he was at the same levels. V2 said his most recent admission was on a Saturday and his referral documents were not reviewed thoroughly at admission. V2 said R1's admitting documents showed he had impaired cognition, increasing forgetfulness, and a history of falls per his wife. V2 said the weekend admission process had holes in it. V2 said staff should have waited until a weekday to admit R1 so a full assessment could be done. V2 said R1 should have been put on one-to-one supervision and in room near the nurses' station as soon as his exit seeking behaviors were seen. V2 said the elopement interventions should have been implemented immediately but were not done until he was found and returned to the facility. R1's care plan showed a focus area for risk for elopement due to an elopement event on 11/20/22. The initiation date and interventions were dated 11/21/22. The facility's Elopements Policy, with a revision date of 12/2007, states: All residents will be assessed for behaviors or conditions that put them at risk for elopement. The procedure section states: 1. Using the MDS resident assessment schedule, all residents shall be reviewed for safety concerns and precautions. Residents at risk for elopement shall be identified and documented in the individual plan of care. 2. Unless otherwise identified in a plan of care, residents who are at risk for possible elopement shall be accompanied when leaving the facility grounds. The resident representative shall sign the resident out of the facility on the resident sign-out sheet. 3. Residents at risk for elopement shall be identified on a Resident Watch list as well as in the clinical record. This list shall be updated whenever new resident safety issues are identified and shall be located at nursing stations and the reception area. The Immediate Jeopardy that began on 11/20/22 was removed on 11/21/22 when the facility: 1. Resident R1 readmitted back to the facility on [DATE]. Re-assessed for risk of elopement, 1:1 supervision implemented. Completed on 11/20 and currently on-going. On 11/21 instructed SS (social services) for alternate placement for safety and to meet resident's needs. Administrator and SS had a conversation with POA/wife of R1, who agreed to assessment for alternate placement, SS currently actively searching for appropriate placement. On-going. 2. 100% Staff education began on 11/20/2022 PM shift. Staff that were not reachable will be educated prior to working their next shift. Contracted staff will also be included in all required education. 11/20/22 PM and NOC [night] shift; 11/21/22 Day, PM and NOC shift were educated, Elopement Drills on Day, PM, and NOC shifts. Employee Roster printed, staff aware that they cannot work until they have received and signed off on the in-service. All PRN [as needed], on vacation, on leave staff being contacted to give education, currently on-going. 11/20 all completed as per staff schedule. 11/21 all completed as per staff schedule. 11/22 all completed as per staff schedule. 11/23 ongoing education continues. 3. All staff have been educated on the elopement policy and procedure, reporting criteria, immediate reporting to the administrator or DON, recognizing elopement, steps to take immediately after an elopement or the alarm system is triggered, and elopement prevention. Trainings specifically include the review of the policy and procedure which includes but is not limited to elopement drills. Completed on 11/21/22 and will continue a quarterly basis. 4. The Administrator and Director of Nursing have been in serviced on Elopement Policy and Procedure including immediate intervention during an elopement, proper and thoroughly investigating elopements, timely reporting, proper protocol during an elopement, completing the process identified in the elopement policy, through investigation process, and providing elopement prevention training to all staff including the elopement policy, recognizing elopement, Education was proved by the administrator or designee. Completed 11/21/2022. 5. All current residents reassessed for elopement risk. All high risk for elopement residents' care plans reviewed and appropriate interventions implemented and in place to address their high risk for wandering and their Care Plans updated to reflect elopement status. Completed 11/21/22 by Care Plan Coordinator and Social Services. 6. All facility staff re-educated to recognize residents at risk for elopement, where to locate updated and/or current interventions for high-risk residents, how to respond to all door alarms immediately and the facility policy and protocol for Elopement and Annual training will be completed as scheduled annually. Currently on-going. All staff are required to receive education/in-service regarding Elopement prior to start of shift. 7. All facility staffed educated on the process to ensure that high-risk elopement residents are communicated to all staff in the facility. Elopement Binders were updated with pictures and face sheets of high-risk elopement residents. Binders located in both nurses [sic] stations and front desk. Completed 11/21/22. 8. All facility door alarms inspected on 11/21/22 and administrator ensured that door alarms are continuously inspected/audited to ensure proper working order and no doors are propped open. Completed on 11/21/22. 9. Facility Management staff re-educated by regional nurse consultant via telephone on 11/20/22 on reporting elopement incidents to the State Agency. Completed on 11/20/22. 10. Elopement processes and procedures added to the facility's QAA [Quality Assessment and Assurance]/QAPI [Quality Assurance and Performance Improvement] program for ongoing monitoring. Elopement Policy will be discussed during QA [Quality Assurance] meeting with Medical Director on 11/30/22. 100% audit of all elopement risk assessment for accuracy, review of care plans, elopement program evaluation, 100% audit of (brand name of alarm system) function and placement, 100% audit of orders, TAR [Treatment Administration Records] and (brand name of resident chart information) placement, door alarm drills on every shift, and elopement drill completed on all shifts. Completed on 11/21/22 and will follow up with quarterly drills for the coming year. On-going. 11. The Administrator or designee will conduct a rounding audit on the elopement policy/procedure and timely reporting interviewing 5 employees per week including all 3 shifts. Any identified issues or concerns will be immediately addressed. Audits will continue for 4 weeks to determine compliance. Audit started 11/21, ongoing for 4 weeks. 12. An emergency QA meeting was held with the facility Medical Director via telephone, Regional Director, Regional Nurse, Facility Administrator and Director of Nursing to review the abatement plan. Meeting was held on 11/21/22. 13. No staff member or contracted employee will be allowed entry to the facility until they have read and acknowledged elopement procedures. On-going phone calls by DON and ADON for prn and on-vacation staff. 14. All new orientees will be educated upon hire on the elopement policy and procedure. Ongoing. 15. The removal plan will be monitored by the Administrator.

Based on interview and record review the facility failed to identify a resident's (R1) pressure injury prior to the injury (left ischium/hip) becoming unstageable. The facility failed to provide ongoing assessments and monitoring of R1's unstageable left ischial pressure injury. The facility did not follow their care plan as evidenced by not assessing the wound weekly. These failures resulted in R1 being hospitalized for an acute infection to the left ischial pressure injury that required surgical intervention. These failures apply to 1 of 3 residents (R1) reviewed for pressure injuries in the sample of 3. The findings include: R1's care plan dated January 5, 2022 showed R1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan showed R1 was at increased risk of additional skin breakdown/pressure injuries related to his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan showed an intervention to monitor bony prominences for redness and monitor the skin and assess every week. An outpatient wound care clinic note dated January 14, 2022 showed R1 was to be been seen weekly, in the clinic, for the treatment and management of his chronic foot wounds only. If R1 developed any pressure injuries in the facility, those injuries were to be treated by the facility's wound care team. R1's admission assessment dated [DATE] showed R1 was admitted to the facility with no pressure injuries to his left ischium/hip. R1's weekly skin check note dated April 21, 2022 showed no pressure injuries to R1's left ischial area. A Skin and Wound Evaluation dated April 27, 2022 showed R1 was found to have a new, unstageable, pressure injury to his left ischial area that measured 2.3 cm(centimeters) x 2.5 cm x 0.3 cm. On July 6, 2022 at 9:40 AM, V3 (Wound Nurse) stated R1 was at high risk for skin breakdown upon admission to the facility. V3 stated, I am not sure how (R1's) left ischial wound was not found until it was unstageable .The verbal agreement was that when (R1) was admitted to us, we would manage and treat any pressure injuries he may have or develop while here. He went out to a wound care clinic, once a week, for treatment and management of his chronic foot wounds. They treated his foot wounds. We treated his pressure injuries . Once a resident develops a pressure injury, the injury is to be assessed and measured once a week by myself and the wound doctor. I am responsible for completing the weekly wound assessments on any resident's pressure injuries. I complete the weekly assessments once the wound doctor and I have rounded on the resident. The nurses and CNAs (certified nursing assistants) should be monitoring the wounds daily, during cares, for any changes. R1's weekly Skin and Wound Evaluations for May 2022 were reviewed and showed no assessments of R1's left ischial wound were completed the weeks of May 2, 2022, May 16, 2022, and May 30, 2022. On July 5, 2022 at 1:30 PM V3 (Wound Nurse) was asked about R1's missing weekly wound assessments for May 2022. V3 stated, I don't know why they weren't done. They should have been. Maybe (R1) was at his weekly outpatient wound clinic appointments for his feet so he might have been out of the facility. R1's weekly Skin and Wound Evaluations of R1's left ischial pressure injury, dated June 9, June 16, and June 21, 2022, were reviewed. R1's assessment dated [DATE] showed R1's left ischial wound was worsening in condition and had become bigger in size with measurements of 5.3 cm x 4.5 cm x 1.8 cm. R1's June 2022 medical records, including all progress notes and skin assessments, were reviewed and showed no additional assessments were completed on R1's left ischial wound from June 22-June 30, 2022. A Wound Care Clinic note dated June 30, 2022 showed R1 arrived to the outpatient wound care clinic for weekly management of his chronic foot wounds. The note showed, In December (2021), the patient had a small stage 2 pressure injury to the left ischium. The nursing home insisted that there in house wound care would manage the ischial ulcer and the Wound Care Clinic was to only mange the foot wounds. The patient was complaining of great pain today and the ischial dressing was removed. The wound is grossly infected with [CONDITION(S)] and foul odor. The bone (hip) is not quite palpable at this time but there is only a very thin layer of tissue protecting it. Patient complains of great pain to this area . The note showed R1's left ischial pressure injury measured 3.5 cm x 6 cm x 3.8 cm with a wound depth of 6 cm in one area of the wound. The note showed R1 was sent immediately, by ambulance, to a local hospital for an evaluation of the wound. R1's hospital records dated June 30, 2022-July 4, 2022 showed R1 was admitted to the hospital with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The records showed R1 underwent surgical debridement of his wound on July 1, 2022. On July 5, 2022 at 11:30 AM, V4 (Outpatient Wound Clinic Nurse Practitioner) stated, We had been treating (R1) weekly for his chronic foot wounds since December 2021. He did have a history of a small pressure injury to his left ischium that was noted in December. When (R1) was admitted to the facility in January 2022, we were told by the facility that they would manage any of (R1's) pressure injuries and we would manage his foot wounds. On June 30, 2022, (R1) came to our clinic for his weekly appointment. You could smell his infection the minute you entered his room. He didn't have that odor when we saw him on June 23rd for his previous appointment. He was complaining of pain to his left hip. He couldn't move on his own at all, so we got him out of the wheelchair and got him onto the bed. We removed the dressing to his left hip and found a circular wound that was the size of my fist. It was so foul smelling and infected. The wound was slightly necrotic, with thick yellow drainage. That wound had been like this for at least 3-4 days prior. I sent him immediately to the emergency room . An unstageable pressure injury should be monitored at least weekly, if not daily, especially if you are concerned the wound is getting infected. (R1) got that injury from pressure. He was laying in one position for too long. He was too weak to reposition himself without our help .He was at high risk for skin breakdown, but his unstageable pressure wound did not just develop overnight . On July 5, 2022 at 3:50 PM, V11 (R1's Hospital Physician) stated, Unfortunately, (R1) has taken a turn for the worse today and is now in septic shock. I don't know if he is septic because of his left ischial wound or because of the wound to his right foot .What I can tell you is that when (R1) presented to the emergency room (on 6/30/22), he had a grossly infected wound to his left ischium. It smelled foul and contained a large amount of necrotic tissue. His wound had been badly infected for a while . On July 6, 2022 at 9:40 AM, V3 (Wound Nurse) stated she was unable to find any facility documentation and/or assessments of R1's left ischial wound that were completed from June 22-30, 2022. V3 stated she did not reassess R1's left ischial wound from June 22-30, 2022. V3 stated, When we (wound care team) saw (R1) on June 21, 2022, I was concerned his wound (left ischium) was getting infected, but he was already on an antibiotic for an infection to his right foot. Staff should have been assessing his left ischial wound every day for any changes and reporting any changes immediately .I am not sure why his wound wasn't reassessed during that time. It should have been assessed daily by staff when the dressing was changed . On July 5, 2022 at 1:50 PM, V2 (Director of Nursing) stated the facility did not have a policy on the treatment and management of a resident's pressure injuries.

Based on observation, interview, and record review the facility failed to implement dietician recommendations for 1 resident (R35) and failed to monitor weights for new admissions for 2 residents (R33, R56) for 3 of 5 residents (R33, R35 and R56) reviewed for nutrition. These failures resulted in 1 resident (R35) not receiving the recommended amount of artificial nutrition to maintain R35's body weight that resulted in a 4.9lb (2.6%) weight loss within 1 month. R33's weight records showed from 10/1/21 to 10/12/21, R33 experienced a weight loss of 10.6lbs (10.7%). The findings include: 1) R35's electronic face sheet printed on 11/18/21 showed R35 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] & reflux [CONDITION(S)], dementia without behaviors, and cerebral infarction. R35's facility assessment dated [DATE], showed R35 has severe cognitive impairment, unplanned weight loss, and has a feeding tube. R35's care plan dated 10/27/21 showed, (R35) requires tube feeding due to dysphagia. Registered dietician to evaluate quarterly and as needed. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. Enteral feeding: (brand name of tube feeding) 1080cc to run at 40cc/ml until total volume consumed. R35's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . May turn off for short periods of time for care and services. Verify total volume infused prior to turning off. R35's registered dietician progress notes dated 10/27/21 showed, Enteral feeding review .October weight 185.1lbs .Resident with insidious weight loss within the past 180 days (loss of 19.9lbs=9.8%) which is unplanned. Usual weight ranges from 198-207lbs. Feeding via tube of (brand name tube feeding) 960cc to run at 40cc/hr. Estimate residents nutritional needs at 2000-2200cal and fluids at 2000-2200cc. Current enteral feeding is meeting 86% of estimated calories. Recommend increase rate of (brand name of tube feeding) to 45cc/hr until total volume of 1080cc is infused. On 11/17/21 at 8:59AM, R35 was sleeping in his bed. R35's tube feeding was running via feeding pump at a rate of 40cc/hr. (22 days after the registered dietician recommended an increase to 45ml/hr). R35's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . May turn off for short periods of time for care and services. Verify total volume is infused before turning off. R35's weight log showed a 4.9lb weight loss within 8 days from 11/2/21 to 11/10/21. On 11/17/21 at 12:40PM, V4 (Registered Nurse) stated, (R35) just came back from the hospital not long ago. His current tube feeding orders are (brand name tube feeding) at 40cc/hr. I'm not aware of any increase in R35's feeding rates. When the dietician comes, she makes recommendations and puts the recommendations in the nurse practitioner's box to be signed. The nurse practitioner comes every Tuesday & Friday for the most part. After the nurse practitioner signs orders she gives them to (V2-Director of Nursing) to be entered into the system. If a resident does not get the proper nutritional value and we don't monitor weights, then we could miss a weight loss and it puts a resident at risk for further weight loss or even an unnecessary weight gain in some situations. On 11/18/21 at 9:51AM, V2 (Director of Nursing) stated, I just received the 10/27/21 dietician recommendation for (R35) on 11/17/21. Usually, the nurse practitioner is here Tuesday and Friday to sign off on orders. There is no reason why I should just now be getting these orders given to me. I would agree that we do not have a good system. This was a large delay and should have been handled earlier. (R35) has now suffered because of it. It looks like (R35) has had weight loss since this recommendation and it's probably because (R35) hasn't been getting the right amount of tube feeding. As of 11/18/21 the facility was unable to provide a policy related to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/18/21 at 1:00PM, V2 stated that tube feedings are a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) R33's electronic face sheet printed on 11/18/21 showed R33 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R33's facility assessment dated [DATE] showed R33 has no cognitive impairment and receives tube feedings. R33's weight records showed from 10/1/21 to 10/12/21, R33 experienced a weight loss of 10.6lbs (10.7%). As of 11/18/21, no further weights had been documented for R33. R33's care plan dated 10/4/21 showed, (R33) requires tube feeding related to dysphagia. (R33) will maintain adequate nutritional and hydration status as evidenced by weight stability, no signs or symptoms of malnutrition or dehydration through review date. R33's care plan dated 10/6/21 showed, The resident meets criteria for severe malnutrition related to history of weight loss, dysphagia, low body mass index. Resident receives nothing by mouth. On 11/18/21 at 9:51AM, V2 stated, I only see that (R33) was weighed twice since admission on 10/1/21. (R33) should have been weighed for the first 4 weeks after admission per our policy and then monthly after that. We are missing 2 weeks' worth of weights for (R33) at the end of October and we have not done (R33's) November weight yet. It is important to weigh our residents as ordered, especially those receiving tube feedings because that is how the dietician bases her recommendations on increasing or decreasing tube feedings. The facility's policy titled, Nutrition (Impaired)/unplanned weight loss-clinical protocol with a revision date of February 2021 showed, 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. As of 11/18/21 the facility was unable to provide a policy indicating how often weights are performed. 3) R56's electronic face sheet printed on 11/18/21 showed R56 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R56's facility assessment dated [DATE] showed R56 has mild cognitive impairment and receives tube feedings. R56's weight records dated 10/26/21 showed R56 weighs 111.2lbs. No further weights had been obtained for R56 since his admission to the facility. R56's care plan dated 10/27/21 showed, The resident requires tube feeding due to dysphagia, history of [CONDITION(S)] disease, severe malnutrition, low body mass index, weight loss, and inadequate oral intake. On 11/18/21 at 9:35AM, V2 (Director of Nursing) stated, (R56) is missing 2 weeks' worth of weights and I'm not sure why. The order for (R56) is not present for weekly weights. (R56) is on a tube feed and if (R56) has lost or gained weight that would affect (R56's) tube feeding rates to ensure (R56) is not getting too much or too little to eat.

Based on observation, interview and record review, the facility failed to transfer R1 in a safe manner. This failure resulted in R1 having to be lowered to the floor, sustaining a fracture to her right femur. This applies to 1 of 4 residents (R1) reviewed for transfers in the sample of 4. The findings include: The Physician order [REDACTED]. The Minimum Data Set (MDS) dated [DATE] shows R1 is severely cognitively impaired and needs extensive assist of 2 or more staff for bed mobility and transfers. A progress note for R1 dated April 17, 2016 documented by E3 RN (Registered Nurse) shows that E4 CNA (Certified Nursing Assistant) lowered R1 to the floor during transfer from bed to chair. R1 laid on her right side. E4 then assisted R1 into padded reclining chair. R1 was already in her padded reclining chair in the hallway before E4 notified E3. The Assessment of R1 showed an increase in agitation, combativeness and striking out. R1 was uncooperative with ROM (range of motion) in the upper extremity. On May 2, 2016 at 10:05 AM, R1 was in bed asleep with immobilizer intact on her right leg. On May 2, 2016 at 10:20 AM, E3, said that on April 17, 2016 she was informed by E4 that she was in the process of transferring R1 and had to lower R1 to the floor. E4 had assisted R1 to her chair before E4 made E3 aware of the incident. E3 stated the protocol for this facility is no resident should be moved without the nurse assessing the resident first. E3 said E4 transferred R1 by herself. E3 said, R1's transfer status should always be 2 person assist. E3 also said during her assessment with R1, R1 was agitated and combative. On May 2, 2016 at 10:45 AM, E4 said that on April 17, 2016, she was trying to transfer R1 by herself from bed to her padded reclining wheelchair. E4 said during the transfer, she (E4) kicked the garbage can and lost her balance so she was not able to completely put R1 in her chair. R1 was on the edge of the chair. E4 said she was not able to lift R1 to position her better to the chair, so she sat R1 down to the floor. R1 was on her right side with her knees towards the left. E4 stated I lifted R1 by myself from (the) bed to (the) chair. E4 said she lifted R1 again by herself from the floor to the bed. E4 said she is aware that R1 is a two staff assist on transfers but the other CNA's were busy. E4 also said she did not tell the nurse about what happened until R1 was already back in her chair sitting in the hallway. May 2, 2016 at 10:40 AM, E2 (Director of Nursing) said R1 is a 2 transfer assist. E2 also said, residents that had fallen should never be moved until a nurse has assessed the resident and safe to be moved. On May 2, 2016 at 12:00 PM, Z2 (Hospice RN) and Z3 (Hospice CNA) both said they were in the facility on April 20, 2016. (three days after the incident.) R1's right leg was swollen and R1 was complaining of pain in her right leg. R1's Doctor was notified and an order for [REDACTED]. The radiology report dated April 21, 2016 shows R1 has a Fracture of the femur. On May 2, 2016 at 1:30 PM, Z1 (physician) said R1's fracture in the Right Femur was caused by the fall (on April 17, 2016.) R1's fall risk assessment dated [DATE] shows R1 is high risk for falls. R1's Care Plan on Activities of Daily Living with a revision date of November 20, 2016 shows R1 is a 2 person extensive assistance with transfers. R1's Fall Care Plan dated June 2, 2015 shows R1 has gait/balance problems but did not show any interventions on transfers A facility document entitled in service Education dated April 21, 2016 states: If a resident experiences a change of place (falls) prior to assisting resident to original position, (an) assessment must be completed by (a) nurse before assisting a resident. On May 2, 2016 at 2:35 PM E2 said the facility has no policy on Transfers.

Based on interview and record review the facility failed/neglected to follow and implement the facility's policy and procedure for "Pressure Ulcer Prevention" in the following areas; 1. Assessment; - A standardized pressure ulcer risk assessment (Braden Scale) will be used to identify residents who are at risk for the development of pressure ulcers. This assessment will be completed upon admission, weekly x 4 weeks, quarterly and when a significant change in the resident's condition is noted. 2. Planning: - An individual plan of prevention will be developed to meet the needs of the resident. It will include the consideration of mechanical support surfaces, nutrition, hydration, positioning, mobility, continence, skin condition and overall clinical condition of the resident as well as the risk factors as they apply to each individual. 3. Implementation: - Interventions for the prevention of pressure ulcers will be individualized to meet the specific needs of the resident. Interventions will consider the assessment of risk and skin condition of the resident. 4. Evaluation and Reassessment: - The facility's Care Management System committee will review program components to evaluate the effectiveness of the prevention program and facility systems. Findings and recommendations will be reviewed with the QA Clinical Committee. Based on evaluation, the need for reassessment and further changes to the individual resident' plan of care will be determined and acted upon. This is for 5 (R4, R5, R6, R8, R14) of the 7 residents sampled for pressure sores in a total sample of 21 with 3 residents (R24, R25 and R26) in the supplemental sample. These failures contributed to the development and worsening of avoidable facility acquired pressure sores in various stages for these 8 residents. Findings include; A review of the facility's "Resident Census and Conditions of Residents" under section "D" Skin Integrity noted that the facility reported 13 residents with pressure sores and only 2 of these residents had pressure sores on admission. In an interview on 8/16/11 at 2:30 PM with E1, the administrator and E2, the director of nursing, they stated that they are aware of the problem regarding pressure sores recently acquired in the facility. E1 stated that they are looking at the reasons why this occurred. E1 stated that in July 2011 the facility census went from 90 to over 100 and that the facility had to hire more staff to meet the needs of their residents. E1 stated that the care was not given as it should be regarding pressure sore prevention because they did not have enough staff. On 8/17/11 at 10:15 AM E1 stated that after looking at the staffing, they now believe that staffing was sufficient. E1 stated that the facility experienced power outages that utilized the back-up generator. E1 stated that the primary goal during these power outages was making sure the residents were hydrated. E1 stated that perhaps some preventive care was overlooked at this time. In an interview on 8/22/11 at 9:30 AM with Z1, the medical director, he states that he was aware of the facilities acquired pressure sores in the quarterly quality assurance meetings. Z1 states that he was probably informed of the increasing numbers of acquired pressures sore but he does not recall how many the facility has. Z1 states that he believes in the general philosophy of pressure sore prevention that includes skin checks, frequent repositioning and incontinence care. Z1 states that the facility needs to be vigilant in these preventive measures. Z1 states that there was a breakdown in these processes but he cannot say where the breakdown occurred. Z1 states that he was not involved in recommending interventions but that he did agree with the plan of removal regarding the immediate jeopardy situation. 1. On 8/16/11 at 10:10 AM R5 was in bed waiting for her dressing change. E6, the wound care nurse, removed R5 ' s coccyx dressing. R5 ' s wound is a Stage 3 pressure ulcer measuring 2.1 centimeter (cm) by 1.3cm by .2cm depth. The pressure sore has a thin center yellow slough approximately 25%. These measurements confirms a worsening of the pressure sore. The record of R5, a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R5 ' s record contains a physician ' s treatment order dated 7/18/11 that states. " Cleanse coccyx with sterile normal saline apply [MEDICATION NAME] AG and a 4 by 4 Exuderm every 3 days and as needed until resolved. " R5 ' s record contains a " Braden " pressure sore scale dated 6/13/11 that states she scored a 15 which is considered " mild risk " The minimum (MDS) data set [DATE] states that she needs extensive assistance to transfer, assistance to position herself in bed, and uses a wheelchair for ambulation and is incontinent of bowel and bladder. R5's "Weekly Pressure Ulcer Assessment" sheet dated 7/18/11 that states this is the date that a stage 2 coccyx pressure sore was identified and measured .52 cm by .51cm. R5's "Weekly Pressure Ulcer Assessment" dated 7/26/11 states that the wound is now 1.5cm by 1.5cm by .1 depth which is a worsening of the pressure sore. R5's "Weekly Pressure Ulcer Assessment" sheet dated 8/2/11 states that her pressure sore is a stage 3 measuring 1.5cm by .8cm by .2cm with 50% necrotic tissue, this is a significant worsening of the pressure sore. R5's "Weekly Pressure Ulcer Assessment" sheets show a decline or worsening in the pressure sore every week. The physician's orders [REDACTED]. R5's record lacks a comprehensive plan of care to prevent and treat pressure ulcers. In an interview with E6, the wound care nurse, she states that some physician's utilize a wound care clinic and some do not. E6 stated that some physician's are open to treatment suggestions and some are not. E6 stated she does not remember which residents have physician's that will use a wound clinic. E6 stated that she is aware that the wound is worse than it was previously. 2. On 8/16/11 at 10:20 AM R14 was in bed waiting for her heel dressing to be changed. R14 has an unstageable pressure ulcer to her left heel measuring 4.0cm by 5.0 cm by .1 cm at the periphery of the wound. R14's wound has a black eschar center (75%) with surrounding red tissue. This is a worsening of the "suspected deep tissue injury" that was documented on 8/9/11. The record of R14,an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R14's record contains a "Braden Scale for Predicting Pressure Sore Risk" dated 7/11/11 that states she scored a 22 which is "mild risk" on this scale. R14's record contains a "Weekly Pressure Ulcer Assessment' dated 8/5/11 that states a suspected deep tissue injury was found and measured 5.2cm by 5.9cm and depth is stated as "blister". R14's record contains a physician's orders [REDACTED]. Apply skin prep to intact blister, cover with [MEDICATION NAME] and wrap with kerlix." R14's record contains a Minimum Data Set ((MDS) dated [DATE] that states she needs assistance with bed mobility, transfers dressing and hygrine. R14's MDS states that she uses a wheelchair for ambulation and she continent of bowel and bladder. In an interview with E6,the wound care nurse, she stated that she does not know how this resident developed her pressure sore and that her assessments states she was at low risk for development of pressure sores. 3. On 8/16/11 at 10:00 AM E6 stated that R4 was admitted to the hospital last night due to her pressure sores. E2, the director of nursing, presented a history and physician report from the hospital regarding R4. This report states "...She is here from the nursing home with chief complaint of right foot pain and right foot drainage...Family also noted that the patient also had decubitus ulcers for some time but noted increased wound care needs for the past month...2 unstageable ulcers on the patient's right foot, foul smelling with necrotic tissue present. Also deep tissue injury in the medial right knee and decubitus on the right hip...Will be consulting surgery for [REDACTED]. The record of R4's record contains an [AGE] year old female admitted to the facility in June of 2010 with [DIAGNOSES REDACTED]. R4's MDS dated [DATE] states that she requires assistance with turning in bed, transferring, dressing and bathing. R4's MDS also states that she is frequently incontinent of both bowel and bladder and that she uses a wheelchair for ambulation. E4's record contains a "Braden scale for predicting pressure sore risk" dated 7/6/11 that states a score of 10 that signifies "high risk" for pressure sores. R4's record contains "Weekly Pressure Ulcer Assessment" dated 6/16/11 that states this date is when a stage 3 right hip pressure ulcer was identified and measured 3cm by 1.8cm by .2cm with 60% necrotic tissue. R4's record contains a "Weekly Pressure Ulcer Assessment" dated 8/6/11 that states a stage 2 left medial knee pressure ulcer was noted measuring 3cm by 2cm by .2cm depth. R4's record contains a "Weekly Pressure Ulcer " dated 8/9/11 that states the left medial knee pressure sore is now a stage 3 with 75% necrotic tissue. 4. On 8/16/11 at 11:00 AM R25 was in bed waiting for her dressing change. E6 measured the right buttock wound at .3cm by .2cm by .1 cm depth and a Stage 2 pressure ulcer. The wound was bleeding slightly. E6 stated that she does not know why R25 developed this pressure ulcer. The record of R25 a [AGE] year old female admitted to he facility with [DIAGNOSES REDACTED]. R25's record contains a "Braden Scale for Predicting Pressure Sores" that state she scored an 11 on 7/24/11 which is considered "High Risk" R25's record contains a "Weekly Pressure Ulcer Assessment" dated 8/2/11 that states she acquired a left buttocks stage 2 pressure ulcer measuring .5cm by .8cm by .1 cm depth. R25's record contains an MDS dated [DATE] that states she required extensive assistance to transfer and toilet and some assistance for bed mobility and dressing. This MDS states R25 used a wheelchair for ambulation and that she is incontinent of uri ne and occasionally incontinent of bowel. 5. On 8/16/11 at 10:30 AM R6 was in bed waiting for her dressing change. E6 measured her right hip Stage 2 pressure sore as .5cm by .5cm and her [MEDICATION NAME] spine Stage 2 pressure sore as .8cm by .7cm by .1 cm depth. E6 states that she does not know why this resident developed her pressure sores. The record of R6 a [AGE] year old female admitted tot he facility with diagnoses(co morbidities) including [MEDICAL CONDITION], Late Effect [MEDICAL CONDITION] and Muscle Weakness was reviewed. R6's record contains a "Weekly Pressure Ulcer Assessment" dated 6/4/11 that states she acquired a [MEDICATION NAME] spine Stage 2 pressure sore measuring .3cm by .3cm by .1cm. R6's record contains a "Weekly Pressure Ulcer Assessment" dated/12/11 that states she acquired a right hip pressure sore measuring 1.3cm by .2cm. R6's record contains an MDS dated [DATE] that states she required extensive assistance with transfers, dressing and hygiene. This MDS also states that she is incontinent of bowel and bladder. 6. On 8/16/11 at 11:50 AM R24 was in bed waiting for her dressing change. E6 measured her left buttock Stage 2 pressure sore 1cm by .5cm by .1 cm depth. This wound was bleeding slightly. E6 stated that she does not know why R24 developed a pressure ulcer. The record of R24 an [AGE] year old female admitted to the facility with [DIAGNOSES REDACTED]. R24's record contains a "Braden Scale for Predicting Pressure Sore Risk" dated 8/5/11 that scores her a 15 which is considered "Mild Risk". R24's record contains a "Weekly Pressure Ulcer Assessment" dated 8/5/11 that states her right inner buttock Stage 2 pressure ulcer measured 1.6cm by .6cm by .001 cm depth. R24;s record contains a MDS dated [DATE] that states she requires extensive assistance to transfer and for dressing. This MDS also states that R24 requires assistance with bed mobility, eating and hygiene and that she is frequently incontinent of urine and occasionally incontinent of bowel. 7. On 8/16/11 E6 stated that R26 refused to have another dressing change for observation purposes. On 8/18/11 E1, the administrator stated that R26 was being admitted to the hospital due to respiratory problems. The record of R26 an [AGE] year old female admitted to the facility with [DIAGNOSES REDACTED]. R26's record contains a "Braden Scale for Predicting Pressure Sore Risk" dated 8/6/11 that scores her 15 which is considered "Mild Risk". R26's record contains a "Weekly Pressure Ulcer Assessment" dated 8/6/11 that states she developed a right inner buttock pressure sore measuring .8cm by 1 cm by .01 cm depth. R26's record contains an MDS dated [DATE] that states she requires extensive assistance for transfers, dressing and hygiene. This MDS also states that she requires assistance with bed mobility. This MDS also states that R26 is incontinent of bowel and bladder. 8. On 8/16/2011 at at 11:45 A.M., R8's skin condition was checked in the presence of E10 (CNA-certified nurse assistant). R8 has a stage II pressure ulcer on her right upper spine. Review of record "Monthly Skin Assessment" dated 8/8/2011 showed that R8's pressure ulcer measures 1.5 x 3x 0.1 cm. According to R8's record,this pressure ulcer was first identified and was acquired by R8 at the facility on 8/8/2011. Review of current care plan indicated that R8 was identified with at risk for pressure ulcers related to declining condition, incontinence of bladder and bowel, history of [MEDICAL CONDITION], right sided weakness and loss sensation in feet. The care plan indicates that interventions to address R8's pressure ulcer includes for R8 to be placed on a pressure redistributing mattress in bed and wheelchair cushion. R8 was observed on 8/15/2011 at around 10:30 A.M., 8/16/2011 at 12:30 P.M., and 2:30 P.M. R8 was sitting in a reclining wheelchair. Further observation showed that R8 was sitting directly on the reclining wheelchair without a pressure redistribution chair cushion. On 8/16/2011 at 2:30 P.M., E13 (CNA) stated that she never had seen R8 's reclining wheelchair cushion. On 8/16/2011 at 3:10 P.M. during the daily status meeting, the concern that R8 was without redistribution cushion in a reclining wheelchair was discussed with E1 (Administrator) and E2 (Director of Nursing). On 8/17/2011 at 12:30 P.M., R8 was observed in the main dining room. R8 was sitting on a reclining chair. R8 was still without a pressure redistribution cushion. E5 (Assistant Director of Nursing) was present during this observation. All of the documentation presented by the facility was reviewed.

Based on observation, interview and record review the facility failed to: 1. Implement a pressure ulcer intervention to prevent the development of facility acquired pressure ulcers for eight residents R4 and R14 with Un-stageable pressure sores, R5, R6 and R8 with Stage 3 pressure sores, R24 and R25 with Stage 2 pressure sores and R26 with a stage 1 pressure sore), and 2. Provide the necessary care and services to promote healing, and prevent developed pressure sores from worsening for three residents (R5 and R4). This is for 5 of the 7 residents sampled for pressure sores in a total sample of 21 with 3 residents in the supplemental sample. These failures contributed to the development and worsening of avoidable pressure sores in various stages for these eight residents. Findings include; 1. On 8/16/11 at 10:10 AM, R5 was in bed waiting for her dressing change. E6, the wound care nurse, removed R5 's coccyx dressing. R5 's wound is a Stage 3 pressure ulcer measuring 2.1 centimeter (cm) by 1.3cm by .2cm depth. The pressure sore has a thin center yellow slough approximately 25%. These measurements indicate a worsening of the pressure sore. The record of R5 noted a [AGE] year old female admitted to the facility with [DIAGNOSES REDACTED]. R5 's record contains a physician's treatment order dated 7/18/11 that states. " Cleanse coccyx with sterile normal saline apply [MEDICATION NAME] AG and a 4 by 4 Exuderm every 3 days and as needed until resolved. " R5's record contains a " Braden Pressure sore scale" dated 6/13/11 that states she scored a 15 which is considered " mild risk " The minimum (MDS) data set [DATE] states that she needs extensive assistance to transfer, assistance to position herself in bed, and uses a wheelchair for ambulation and is incontinent of bowel and bladder. R5's "Weekly Pressure Ulcer Assessment" sheet dated 7/18/11 noted that a Stage 2 coccyx pressure sore was identified and measured .52 cm by .51cm. R5's "Weekly Pressure Ulcer Assessment" dated 7/26/11 states that the wound is now 1.5cm by 1.5cm by .1 depth which is a worsening of the pressure sore. R5's "Weekly Pressure Ulcer Assessment" sheet dated 8/2/11 states that her pressure sore is a stage 3 measuring 1.5cm by .8cm by .2cm with 50% necrotic tissue, this is a significant worsening of the pressure sore. R5's "Weekly Pressure Ulcer Assessment" sheets show a decline or worsening in the pressure sore every week. The physician's orders [REDACTED]. R5's record lacks a comprehensive plan of care to prevent and treat pressure ulcers. In an interview with E6, the wound care nurse, she states that some physician's utilize a wound care clinic and some do not. E6 stated that some physician's are open to treatment suggestions and some are not. E6 stated she does not remember which residents have physician's that will use a wound clinic. E6 stated that she is aware that the wound is worse than it was previously. 2. On 8/16/11 at 10:20 AM R14 was in bed waiting for her heel dressing to be changed. R14 has an unstageable pressure ulcer to her left heel measuring 4.0cm by 5.0 cm by .1 cm at the periphery of the wound. R14's wound has a black eschar center (75%) with surrounding red tissue. This is a worsening of the "suspected deep tissue injury" that was documented on 8/9/11. The record of R14,an [AGE] year old female admitted to the facility with [DIAGNOSES REDACTED]. R14's record contains a "Braden Scale for Predicting Pressure Sore Risk" dated 7/11/11 that states she scored a 22 which is "mild risk" on this scale. R14's record contains a "Weekly Pressure Ulcer Assessment' dated 8/5/11 that states a suspected deep tissue injury was found and measured 5.2cm by 5.9cm and depth is stated as "blister". R14's record contains a physician's orders [REDACTED]. Apply skin prep to intact blister, cover with [MEDICATION NAME] and wrap with kerlix." R14's record contains a Minimum Data Set ((MDS) dated [DATE] that states she needs assistance with bed mobility, transfers dressing and hygrine. R14's MDS states that she uses a wheelchair for ambulation and she continent of bowel and bladder. In an interview with E6,the wound care nurse, she stated that she does not know how this resident developed her pressure sore and that her assessments state she was at low risk for development of pressure sores. 3. On 8/16/11 at 10:00 AM E6 stated that R4 was admitted to the hospital last night due to her pressure sores. E2, the director of nursing, presented a history and physician report from the hospital regarding R4. This report states "...She is here from the nursing home with chief complaint of right foot pain and right foot drainage...Family also noted that the patient also had decubitus ulcers for some time but noted increased wound care needs for the past month...2 unstageable ulcers on the patient's right foot, foul smelling with necrotic tissue present. Also deep tissue injury in the medial right knee and decubitus on the right hip...Will be consulting surgery for [REDACTED]. The record of R4 an [AGE] year old female admitted to the facility with [DIAGNOSES REDACTED]. R4's MDS dated [DATE] states that she requires assistance with turning in bed, transferring, dressing and bathing. R4's MDS also states that she is frequently incontinent of both bowel and bladder and that she uses a wheelchair for ambulation. E4's record contains a "Braden scale for predicting pressure sore risk" dated 7/6/11 that states a score of 10 that signifies "high risk" for pressure sores. R4's record contains "Weekly Pressure Ulcer Assessment" dated 6/16/11 that states this date is when a stage 3 right hip pressure ulcer was identified and measured 3cm by 1.8cm by .2cm with 60% necrotic tissue. R4's record contains a "Weekly Pressure Ulcer Assessment" dated 8/6/11 that states a Stage 2 left medial knee pressure ulcer measuring 3cm by 2cm by .2cm depth. R4's record contains a "Weekly Pressure Ulcer " dated 8/9/11 that states the left medial knee pressure sore is now a Stage 3 with 75% necrotic tissue. 4. On 8/16/11 at 11:00 AM R25 was in bed waiting for her dressing change. E6 measured the right buttock wound at .3cm by .2cm by .1 cm depth and a Stage 2 pressure ulcer. The wound was bleeding slightly. E6 stated that she does not know why R25 developed this pressure ulcer. The record of R25 a [AGE] year old female admitted to he facility with [DIAGNOSES REDACTED]. R25's record contains a "Braden Scale for Predicting Pressure Sores" that state she scored an 11 on 7/24/11 which is considered "High Risk" R25's record contains a "Weekly Pressure Ulcer Assessment" dated 8/2/11 that states she acquired a left buttocks stage 2 pressure ulcer measuring .5cm by .8cm by .1 cm depth. R25's record contains an MDS dated [DATE] that states she required extensive assistance to transfer and toilet and some assistance for bed mobility and dressing. This MDS states R25 used a wheelchair for ambulation and that she is incontinent of uri ne and occasionally incontinent of bowel. 5. On 8/16/11 at 10:30 AM R6 was in bed waiting for her dressing change. E6 measured her right hip Stage 2 pressure sore as .5cm by .5cm and her [MEDICATION NAME] spine Stage 2 pressure sore as .8cm by .7cm by .1 cm depth. E6 states that she does not know why this resident developed her pressure sores. The record of R6 a [AGE] year old female admitted to the facility with diagnoses(co morbidities) including [MEDICAL CONDITION], Late Effect [MEDICAL CONDITION] and Muscle Weakness was reviewed. R6's record contains a "Weekly Pressure Ulcer Assessment" dated 6/4/11 that states she acquired a [MEDICATION NAME] spine Stage 2 pressure sore measuring .3cm by .3cm by .1cm. R6's record contains a "Weekly Pressure Ulcer Assessment" dated/12/11 that states she acquired a right hip pressure sore measuring 1.3cm by .2cm. R6's record contains an MDS dated [DATE] that states she required extensive assistance with transfers, dressing and hygiene. This MDS also states that she is incontinent of bowel and bladder. 6. On 8/16/11 at 11:50 AM R24 was in bed waiting for her dressing change. E6 measured her left buttock Stage 2 pressure sore 1cm by .5cm by .1 cm depth. This wound was bleeding slightly. E6 stated that she does not know why R24 developed a pressure ulcer. The record of R24 an [AGE] year old female admitted to the facility with [DIAGNOSES REDACTED]. R24's record contains a "Braden Scale for Predicting Pressure Sore Risk" dated 8/5/11 that scores her a 15 which is considered "Mild Risk". R24's record contains a "Weekly Pressure Ulcer Assessment" dated 8/5/11 that states her right inner buttock Stage 2 pressure ulcer measured 1.6cm by .6cm by .001 cm depth. R24;s record contains a MDS dated [DATE] that states she requires extensive assistance to transfer and for dressing. This MDS also states that R24 requires assistance with bed mobility, eating and hygiene and that she is frequently incontinent of urine and occasionally incontinent of bowel. 7. On 8/16/11 E6 stated that R26 refused to have another dressing change for observation purposes. On 8/18/11 E1, the administrator stated that R26 was being admitted to the hospital due to respiratory problems. The record of R26 an [AGE] year old female admitted to the facility with [DIAGNOSES REDACTED]. R26's record contains a "Braden Scale for Predicting Pressure Sore Risk" dated 8/6/11 that scores her 15 which is considered "Mild Risk". R26's record contains a "Weekly Pressure Ulcer Assessment" dated 8/6/11 that states she developed a right inner buttock pressure sore measuring .8cm by 1 cm by .01 cm depth. R26's record contains an MDS dated [DATE] that states she requires extensive assistance for transfers, dressing and hygiene. This MDS also states that she requires assistance with bed mobility. This MDS also states that R26 is incontinent of bowel and bladder. 8. On 8/16/2011 at at 11:45 A.M., R8's skin condition was checked in the presence of E10 (CNA-certified nurse assistant). R8 has a stage II pressure ulcer on her right upper spine. Review of record "Monthly Skin Assessment" dated 8/8/2011 showed that R8's pressure ulcer measures 1.5 x 3x 0.1 cm. According to R8's record,this pressure ulcer was first identified and was acquired by R8 at the facility on 8/8/2011. Review of current care plan indicated that R8 was identified with at risk for pressure ulcers related to declining condition, incontinence of bladder and bowel, history of [MEDICAL CONDITION], right sided weakness and loss sensation in feet. The care plan indicates that interventions to address R8's pressure ulcer includes for R8 to be placed on a pressure redistributing mattress in bed and wheelchair cushion. R8 was observed on 8/15/2011 at around 10:30 A.M., 8/16/2011 at 12:30 P.M., and 2:30 P.M. R8 was sitting in a reclining wheelchair. Further observation showed that R8's was sitting directly on the reclining wheelchair without an pressure redistribution chair cushion. On 8/16/2011 at 2:30 P.M., E13 (CNA) stated that she never had seen R8 's reclining wheelchair cushion. On 8/16/2011 at 3:10 P.M. during the daily status meeting, the concern that R8 was without redistribution cushion in a reclining wheelchair was discussed with E1 (Administrator) and E2 (Director of Nursing) during the daily status meeting. On 8/17/2011 at 12:30 P.M., R8 was observed in the main dining room. R8 was sitting on a reclining chair. R8 was still without a pressure redistribution cushion. E5 (Assistant Director of Nursing) was present during this observation. In an interview on 8/16/11 at 2:30 PM with E1, the administrator and E2, the director of nursing, they stated that they are aware of the problem regarding pressure sores recently acquired in the facility. E1 stated that they are looking at the reasons why this occurred. E1 stated that in July 2011 the facility census went from 90 to over 100 and that the facility had to hire more staff to meet the needs of their residents. E1 stated that the care was not given as it should be regarding pressure sore prevention because they did not have enough staff. On 8/17/11 at 10:15 AM E1 stated that after looking at the staffing, they now believe that staffing was sufficient. E1 stated that the facility experienced power outages that utilized the back-up generator. E1 stated that the primary goal during these power outages was making sure the residents were hydrated. E1 stated that perhaps some preventive care was overlooked at this time. In an interview on 8/22/11 at 9:30 AM with Z1, the medical director, he states that he was aware of the facilities acquired pressure sores in the quarterly quality assurance meetings. Z1 states that he was probably informed of the increasing numbers of acquired pressures sore but he does not recall how many the facility has. Z1 states that he believes in the general philosophy of pressure sore prevention that includes skin checks, frequent repositioning and incontinence care. Z1 states that the facility needs to be vigilant in these preventive measures. Z1 states that there was a breakdown in these processes but he cannot say where the breakdown occurred. Z1 states that he was not involved in recommending interventions but that he did agree with the plan of removal regarding the immediate jeopardy situation.