Every finding on record at Decatur Rehab & Health Care Ct

Based on observation, interview, and record review the facility failed to coordinate and document discharge planning for four (R1, R2, R3, R4) of four residents reviewed for involuntary transfer in the sample list of four. Findings include: The facility's written notification dated 11/1/24, signed by V1 Administrator, documents this letter is to inform the facility's residents that the facility will voluntarily close on 2/1/25; and facility staff, consultants and government agencies are working together to ensure residents find placement at facilities that meet the resident's comprehensive needs and preferences. The facility's undated Closure Plan documents the facility intends to close on 2/1/25 and the plan is to ensure safe, orderly and clinically appropriate resident transfers, and to assure successful adjustment for reach resident with minimal stress. This plan includes the following approximate time frames: notification on days 1-5, resident assessments on days 2-30, and transfer/relocation of residents on days 10-45. The resident assessments to be completed include Medicaid Coverage Determination, Medical and Social Assessments by a nurse and Qualified Mental Retardation Professional, and Psychological Preparation of Residents for Transfer. This plan documents the facility will hold on-site conferences for residents and resident representatives to discuss the relocation plans for each resident; the resident's needs, alternative placement, and preferences will be discussed and family or guardian involvement is essential to assure successful relocation for residents and that residents' rights are protected. On 11/13/24 at 9:40 AM V1 Administrator stated the facility will be closed after the four remaining residents (R1-R4) are discharged today. V1 stated the facility staff found out on 11/1/24 that the facility would be closing, and social services staff and V1 worked with the residents to find placement, and all were able to go to facilities of their choice. At 9:50 AM V1 provided the facility's resident roster dated 11/13/24 that documents R1-R4 are the only residents that reside in the facility. V1 stated R1 and R2 are leaving between 10:00 AM and 10:30 AM, R3 is leaving around 11:00 AM, and R4 is leaving around noon. The facility's ongoing resident move roster documents residents started transferring/discharging from the facility as of 11/5/24. 1.) On 11/13/24 at 9:58 AM R1 was sitting in a wheelchair in the dining room. R1 stated about a week ago the facility notified the residents verbally and in writing that the facility was closing. R1 stated staff have been helping R1 with discharge planning and R1 has decided to transfer to (facility's sister facility). R1 stated R1 was told (sister facility) is similar to this one since it has younger residents and mental health services. R1's Face Sheet dated 8/26/24 documents R1's diagnoses include Schizoaffective Disorder, Major Depression, and Anxiety Disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact. R1's Care Plan dated 7/9/24 does not document discharge planning. R1's Social Service Progress Note dated 11/6/24, recorded by V11 Maintenance Director, documents discussed with R1 today about facility closure and upcoming move. R1's only concern is that R1 would like to continue to receive the same services so R1's mental stability continues to improve. R1 was reassured that the facility would make sure R1 gets to the proper facility with the services that R1 needs. There is no other documentation in R1's medical of coordination of discharge planning, besides this note. 2.) On 11/13/24 at 10:08 AM R2 was lying in bed and stated R2 has lived at the facility for a few years and was told yesterday that the facility is closing. R2 stated he was unsure of where he was transferring to and that no one had talked with him about discharge planning; and R2 has no family involved in his care. On 11/13/24 at 10:11 AM V2 Resident Care Coordinator stated R2 is transferring to (sister facility) today, R2 is alert with confusion and has no guardian or Power of Attorney. V2 stated R2 was aware of R2's discharge today and has been reminded, but R2 must have forgot. R2's Face Sheet dated 8/26/24 documents V12 (R2's Family) as R2's responsible party, and R2's diagnoses include epilepsy, history of traumatic brain injury, and developmental disorder of scholastic skills. R2's MDS dated [DATE] documents R2 has severe cognitive impairment. R2's Care Plan dated 5/9/24 documents the following: R2 wishes to eventually be discharged to another facility, V12 believes R2 needs more care than V12 can provide. The interdisciplinary team will review this with V12 and R2 on comprehensive care plans. Interventions listed are evaluate R2's motivation to return to the community and inform on each comprehensive MDS availability of discussions with a Local Contact Agency to assist with setting up services to discharge to the community. There is no documentation in R2's medical record of the facility's closure and coordination of discharge planning. 3.) On 11/13/24 at 10:00 AM R3 was lying in bed wearing oxygen. R3 stated the facility notified the residents verbally and in writing on 11/1/24 of the facility's closure. R3 provided the written notice of closure that was dated 11/1/24 and documented the facility would close on 2/1/25. R3 stated V1 Administrator has helped R3 with discharge planning and R3 is transferring today to a facility of her choice. At 11:08 AM R3 entered V1's office to say goodbye, R3 was in a wheelchair and wearing oxygen. R3 left the facility with R3's personal belongings. R3's Face Sheet dated 8/26/24 documents R3's diagnoses include Dementia, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Dementia, Cerebrovascular Disease, Anxiety, and Depression; and no family or guardian is listed. R3's MDS dated [DATE] documents R3 has moderate cognitive impairment. R3's November 2024 Physician Orders document R3 receives hospice care. R3's Care Plan dated 10/24/24 documents a problem area for discharge planning to return home, but as of 10/24/24 R3 and R3's family no longer wish for R3 to discharge. Interventions include to encourage R3 to discuss feelings and concerns, and monitor/address episodes of anxiety, fear, and distress, and to inform R3 on each comprehensive MDS of the availability to discuss contacting the Local Contact Agency to assist with setting up services to discharge to the community. R3's Social Services Progress note dated 10/15/24 documents R3's daughter is R3's Power of Attorney. R3's Social Service Progress Note dated 11/6/24, recorded by V11 Maintenance Director, documents V11 discussed R3's upcoming discharge with R3, R3's only concern was where her boyfriend, an unidentified resident, would be transferring to. R3 was reassured that the facility would assist in finding placement for the residents that the residents are happy with. There is no other documentation in R3's medical record of the facility's closure and coordination of discharge planning. 4.) On 11/13/24 at 9:53 AM R4 was walking independently in R4's room and there were boxes of R4's belongings. R4 stated the facility came in here like [NAME] and told us they're closing. R4 stated R4 is transferring to another skilled nursing facility today, which is his choice and close to his family. R4 was unable to say what day R4 was notified of the closure or discharge planning that the facility assisted with. R4 deferred further questioning to the facility's staff and R4's Family (V10). On 11/13/24 at 10:39 AM V10 stated V10 was notified on 11/2/24 of the facility's closure. V10 stated we were given up to 2/1/25 to find placement, but staff have been helpful in finding residents placement sooner than anticipated. V10 stated the facility started transferring residents last week, the facility assisted with discharge planning, and V10 was able to choose the facility for R4 to be transferred to. R4's Face Sheet dated 8/8/24 documents R4's diagnoses include Type Two Diabetes Mellitus, Pervasive Developmental Disorder, Cognitive Communication Deficit, Glaucoma, Sarcoidosis of Lung, History of Traumatic Brain Injury, and other problems related to life management difficulty. R4's MDS dated [DATE] documents R4 as cognitively intact. R4's Care Plan dated 10/25/24 does not include discharge planning. There is no documentation in R4's medical record of the facility's closure and coordination of R4's discharge planning. On 11/13/24 at 12:45 PM R1-R4 had been discharged and there were no residents residing in the facility. On 11/13/24 at 10:12 AM V3 Social Services Assistant stated staff found out on 11/1/24 that the facility was closing and residents and families were notified that same day, and letters were sent out on 11/4/24. V3 stated residents were given opportunity to choose their facilities and they were asked about their preferences, referral packets were sent out and calls were placed to facilities, and residents were accepted to their chosen facilities. At 11:23 AM V3 confirmed V3 had not documented resident discharge planning. On 11/13/24 at 10:16 AM V4 Social Services Director stated V4 assisted in sending referrals to facilities and following up. V4 stated residents were given options and choice of facility, if residents weren't able to decide then it was up to their guardian or family. V4 stated R3 has been involved in discharge planning, but R3 did not get accepted at a few facilities, R3 had no facility preference and has no family. V4 stated R3 has been reminded of being transferred today to (sister facility). At 10:50 AM V4 stated V4 was not sure where discharge planning is documented and V4 was not instructed to document discharge planning. At 11:18 AM V4 stated V4 sent R4's referral packet to (sister facility), per V10's request and V4 spoke to V10 yesterday to inform of discharge plan. V4 stated V4 had not spoken to V10 about discharge planning prior to 11/12/24. On 11/13/24 at 10:52 AM V1 stated staff were notified on 11/1/24 of facility closure by 2/1/25 and that day V1 met with residents in small groups and one to one to notify of the closure and answer any questions. V1 stated residents were asked that day of places they would prefer to be transferred to and we made a list that day. V1 stated management staff followed up with the residents to ask how they were feeling and if they had any questions or concerns. V1 stated V1 called all of the residents' families between 11/2/24 and 11/4/24 to notify of the closure after letters were mailed on 11/1/24. V1 stated all residents were assisted with finding placement in facilities that they wanted to go, all of the facilities have psychiatric services and all but two of those facilities use the same psychiatry provider. V1 stated R3 is on hospice and the same hospice company will continue to follow R3 at the receiving facility, and all of the residents on hospice were able to keep the same hospice company at the receiving facilities. V1 stated we started sending referral packets to facilities last week, which included included face sheets, insurance information, Preadmission Screening and Resident Reviews, trust fund information, Physician Order for Life Sustaining Treatment, Power of Attorney forms, physician orders, progress notes/nursing notes, care plans and laboratory results, as well as additional medical records. V1 stated V1 gave notice to terminate V1's employment as of 11/15/24 and V1 wanted to make sure all of the residents had placement accepted prior to V1's last day. V1 stated V1 has visited residents at their new facilities to follow up after their discharge. V1 stated V1 doesn't know that anything has been documented about each resident's discharge planning, other than the managers documenting the discussion of facility closure in the nursing notes or social service notes. V1 stated V1 did not receive a lot of guidance on what should be documented. V1 stated V11 was assigned to follow up with R1 and R3 regarding discharge. V1 stated V4 should have put in a note for R4's discharge planning and V3 should have put in a note for R2's discharge planning. V1 stated R2 had no facility preference, we had tried to communicate with R2's family (V12), but he is hard to get a hold of and messages were left. V1 stated on 11/5/24 (sister facility) representative came to the facility and talked with R2 about the facility and how it was similar to this one, and R2 was in agreement to transfer there. The facility's undated Transfer and Discharge Policy and Procedure documents: Involuntary transfers or discharges Except for the case of late payment or nonpayment, the facility shall notify the resident and the residents family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record. In all other instances of involuntary transfer or discharge the mandated federal and state 30 day ''Notice Transfer or Discharge will be issued and the following steps taken. 1. The planned involuntary transfer or discharge shall be discussed with the resident, guardian, residents representative and/or the person or agency responsible for the residents placement, maintenance and care in the facility. 2. The discussion shall be carried out by the administrator or his/her designee. The content of the discussion and explanation shall be summarized in writing, including the names of those in attendance. The summary shall be made a part of the residents clinical record. 3. A physicians discharge order shall be obtained in the residents record prior to discharge. 4. Prior to transfer or discharge the Social Service Director shall counsel the resident and summarize the counseling session in the residents record.

Based on observation, interview, and record review the facility failed to provide notice which included date of transfer, discharge location, Office of the State Long Term Care Ombudsman contact information, appeal rights, and contact information for the agencies for advocacy and protection of residents with intellectual/development disabilities and mental illness for four (R1, R2, R3, R4) of four residents reviewed for involuntary transfer in the sample list of four. Findings include: The facility's written notification dated 11/1/24, signed by V1 Administrator, documents this letter is to inform the facility's residents that the facility will voluntarily close on 2/1/25; and facility staff, consultants and government agencies are working together to ensure residents find placement at facilities that meet the resident's comprehensive needs and preferences. This notice does not include the right to appeal, Ombudsman contact information, or contact information for advocacy and protection agencies for residents with intellectual/developmental disabilities and mental illness. The facility's undated Closure Plan documents this closure and relocation plan will be initiated on or about November 1, 2024, and will be completed February 1, 2025; and once placement is determined the facility will notify the resident and family of the proposed relocation and their right to an appeal in accordance with federal and/or state laws. On 11/13/24 at 9:40 AM V1 Administrator stated the facility will be closed after the four remaining residents (R1-R4) are discharged today. At 9:50 AM V1 provided the facility's resident roster dated 11/13/24 that documents R1-R4 are the only residents that reside in the facility. V1 stated R1 and R2 are leaving between 10:00 AM and 10:30 AM, R3 is leaving around 11:00 AM, and R4 is leaving around noon. The facility's ongoing resident move roster documents residents started transferring/discharging from the facility as of 11/5/24. 1.) On 11/13/24 at 9:58 AM R1 was sitting in a wheelchair in the dining room. R1 stated about a week ago the facility notified the residents verbally and in writing that the facility was closing. R1's Face Sheet dated 8/26/24 documents R1's diagnoses include Schizoaffective Disorder, Major Depression, and Anxiety Disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact. 2.) On 11/13/24 at 10:08 AM R2 was lying in bed and stated R2 has lived at the facility for a few years and was told yesterday that the facility is closing. R2's Face Sheet dated 8/26/24 documents V12 (R2's Family) as R2's responsible party, and R2's diagnoses include epilepsy, history of traumatic brain injury, and developmental disorder of scholastic skills. R2's MDS dated [DATE] documents R2 has severe cognitive impairment. 3.) On 11/13/24 at 10:00 AM R3 was lying in bed wearing oxygen. R3 stated the facility notified the residents verbally and in writing on 11/1/24 of the facility's closure. R3 provided the written notice of closure that was dated 11/1/24 and documented the facility would close on 2/1/25. This notice did not include date of transfer, location of discharge, Ombudsman contact information, appeal rights, or contact for information for the advocacy and protection agencies for residents with intellectual/developmental disabilities and mental illness. R3 stated V1 Administrator has helped R3 with discharge planning and R3 is transferring today to a facility of her choice today. R3's Face Sheet dated 8/26/24 documents R3's diagnoses include Dementia, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Dementia, Cerebrovascular Disease, Anxiety, and Depression; and no family or guardian is listed. R3's MDS dated [DATE] documents R3 has moderate cognitive impairment. 4.) On 11/13/24 at 9:53 AM R4 was walking independently in R4's room and there were boxes of R4's belongings. R4 stated the facility came in here like [NAME] and told us they're closing. R4 stated R4 is transferring to another skilled nursing facility today, which is his choice and close to his family. R4 was unable to say what day R4 was notified of the closure or discharge planning that the facility assisted with. R4 deferred further questioning to the facility's staff and R4's Family (V10). On 11/13/24 at 10:39 AM V10 stated V10 was notified both verbally and in writing on 11/2/24 of the facility's closure. R4's Face Sheet dated 8/8/24 documents R4's diagnoses include Type Two Diabetes Mellitus, Pervasive Developmental Disorder, Cognitive Communication Deficit, Glaucoma, Sarcoidosis of Lung, History of Traumatic Brain Injury, and other problems related to life management difficulty. R4's MDS dated [DATE] documents R4 as cognitively intact. There is no documentation in R1's, R2's, R3's, and R4's medical records that the residents and their families/representatives were provided notice, which includes all of the required information, prior to discharging from the facility on 11/13/24. On 11/13/24 at 12:45 PM R1-R4 had been discharged and there were no residents residing in the facility. On 11/13/24 at 10:52 AM V1 stated staff were notified on 11/1/24 of facility closure by 2/1/25 and that day V1 met with residents in small groups and one to one to notify of the closure and answer any questions. V1 stated V1 called all of the residents' families between 11/2/24 and 11/4/24 to notify of the closure after letters were mailed on 11/1/24 by V5 Chief Executive Officer of (contracted company). V1 stated V1 doesn't know that anything has been documented about each resident's discharge planning, other than the managers documenting the discussion of facility closure in the nursing notes or social service notes. V1 stated V1 did not receive a lot of guidance on what should be documented. At 11:52 AM V5 provided a copy of the notice that was sent to residents and families on 11/1/24. At 12:32 PM V1 confirmed no other notices regarding transfers/discharges were provided to the residents/families besides the notice on 11/1/24 by V5. V1 confirmed the written notice provided on 11/1/24 did not include date of transfer, discharge location, Ombudsman information, appeal rights, and advocacy agency for developmental disabilities and mental illness information, and confirmed the facility had residents with developmental disabilities and mental illnesses that were discharged after 11/1/24.

Based on observation, interview and record review the facility failed to assess, monitor, implement pressure relieving interventions, complete treatments, and obtain weekly documentation for a pressure sore for one of one (R31) residents reviewed for pressure sores in a sample list of 34 residents. These failures resulted in R31's right heel pressure sore deteriorating requiring mechanical debridement and delaying prosthetic device placement for R31's Left Below the Knee Amputation. R31's Medical Record documents R31's medical diagnoses of Cardiomyopathy, Diabetes Mellitus Type II, Grade One Diastolic dysfunction, Severe Protein Calorie, Malnutrition, recent Left Below the Knee Amputation and Right Heel Stage 3 Pressure Ulcer. R31's undated Face Sheet documents R31 admitted to facility on 1/15/2024. R31's Nursing Admission assessment dated [DATE] does not document any skin impairment to R31's Right Heel. R31's Nursing Summary dated 2/2/24 documents R31's skin as intact with no skin impairment. R31's Careplan intervention dated 3/5/24 instructs staff to complete a Skin Risk Assessment weekly for four weeks on admission and readmission then quarterly thereafter. This same careplan does not include R31's Right Heel Stage 3 Pressure Ulcer. R31's Minimum Data Set (MDS) dated [DATE] documents R31 as cognitively intact. This same MDS documents R31 requires moderate assistance from staff for toileting, bathing, dressing, personal hygiene, and transfers. R31's Treatment Administration Record (TAR) dated June 2024 documents a treatment order (right heel) starting 6/24/24 to cleanse wound with Normal Saline or wound cleanser. Cover wound bed with honey (medical grade) (not intact skin) and cover with dry dressing daily. This treatment was signed as refused on 6/24/24, 6/25/24 and discontinued on 6/26/24. R31's Nurse Progress Note dated 6/26/24 at 2:00 AM documents Current (Right) Heel treatment discontinued due to (R31's) declination and continues to take dressing off each time applied treatment. Changed back to Skin Prep twice daily. Continue no shoe to Right Foot. Heel protector when up in wheelchair. Float Right Heel when in bed every shift. R31's Nurse Progress Note dated 7/1/24 at 1:00 PM documents Received order for (R31's) Right Heel. Cleanse with wound cleanser or Normal Saline. Cover with honey (medical grade) and dry dressing. Wrap with roll gauze. R31's Nurse Progress Note dated 7/6/24 at 5:00 PM documents Received new order for Doxycycline 100 milligrams (mg) twice daily for ten days for (R31's Right Heel) wound healing. R31's Treatment Administration Record (TAR) dated July 2024 documents a treatment order (right heel) starting 7/15/24 to cleanse wound with Normal Saline or wound cleanser, apply Betadine to cover Eschar/black area, cover with absorbent pad and wrap with gauze twice daily. This same TAR does not document R31's treatment was completed for the evening shift on 7/18 and 7/19, day shift on 7/20 and 7/21 and neither day nor evening shift from 7/22/24-7/31/24. This same TAR does not document weekly skin assessments as being completed on 7/2, 7/9, 7/23 and 7/30/24. R31's Initial Wound Clinic Progress Note dated 7/30/24 documents R31's Right Calcaneus Pressure Ulcer as a Stage 3 wound. R31's Physician Order Sheet (POS) dated September 2024 documents a physician order to Cleanse (R31's) Right Heel wound with wound cleanser, apply Calcium Alginate, and cover with roll gauze or cushion twice daily. The order also instructs staff to apply heel protectors when R31 is up in the wheelchair, float Right Heel when in bed/chair every shift and no shoe for R31's Right Foot. R31's Wound Clinic Progress Note dated 9/10/24, 9/17/24 and 9/24/24 documents R31's Right Calcaneus Pressure Ulcer as a deteriorating Stage 3. These same reports document Heel suspension boot to: (R31) NEEDS HEEL SUSPENSION BOOT. FACILITY TO ORDER This same assessment documents float heels off of bed/chair. (R31) (Right) Heel needs floated 24/7. (R31's) wound has deteriorated and appears to have had more pressure applied to the area. No skin prep or lotion in (R31's) wound. Please lotion (R31's) foot with dressing changes. R31's Medical Record does not document any Skin Risk Assessment since R31's admission on 1/15/24. This same medical record does not document any measurements, or weekly assessment details of R31's Right Heel Stage 3 Pressure Ulcer. On 9/22/24 at 10:15 AM R31 was using her Right Foot to propel herself along in her wheelchair in the main dining room. R31 was not wearing a heel protector nor had her Right Foot floated. Multiple staff present in the main dining room did not encourage/instruct R31 to offload pressure from her Right Heel Stage 3 Pressure Ulcer. On 9/25/24 at 11:35 AM V16 Wound Clinic Nurse Practitioner (NP) stated R31 has been seen at the offsite wound clinic for two months for the treatment of her Right Heel Stage 3 Pressure Ulcer. V16 stated R31 is alert and oriented and needs encouragement and verbal reminders to keep her Right Foot offloaded from any pressure. V16 NP stated R31 will keep her own foot up if you remind her. V16 stated R31 is motivated to get her Right Heel healed up. V16 stated the facility is responsible for reminding R31 to keep R31's Right Foot off of the floor and to not place any pressure on it. V16 NP stated The last few times (R31) has come into the clinic, she is not wearing any heel protector. As soon as (R31's) Right Heel heals up, then we can work on getting her a prosthetic for her Left stump. (R31) is looking forward to that so she can go home. The facility has not helped (R31) facilitate the healing of her Right Heel Pressure Ulcer. (R31's) Right Heel Pressure Ulcer should be healing faster. (R31) has the internal mechanisms and power to get that healed with the help of the facility but unfortunately they (facility) are delaying the healing of her Right Heel Pressure Ulcer due to not making sure that her pressure relief interventions are in place. On 9/25/24 at 2:00 PM V1 Administrator stated R31's Right Heel Stage 3 Pressure Ulcer is facility acquired and has worsened during R31's stay at this facility. V1 Administrator stated (R31) did not have any pressure wound when she was admitted . (R31) was admitted because she had just had her Left Below the Knee Amputation done at the hospital. V1 stated R1 has had two separate pressure ulcers on her Right Heel. V1 Administrator stated R31 previously had a facility acquired Suspected Deep Tissue Injury (SDTI) on the same area on her Right Heel which had healed. V1 stated We (facility) should never have discontinued (R31's) treatment to her Right Heel on 6/26/24. I don't think (R31's) wound was completely healed. Within a week (R31's) Right Heel opened up and now (R31) currently has a facility acquired Right Heel Stage 3 Pressure Ulcer with orders in place. (R31's) Stage 3 Pressure Ulcer should have been listed on her careplan and it wasn't. There are no interventions on her careplan that show that (R31) had an open pressure ulcer. (R31) is alert and oriented but the staff should be providing a heel protector or whatever else she needs and also making sure to remind her to offload pressure to that Right Heel. The facility policy titled Decubitus Care/Pressure Areas revised January 2018 documents it is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. The pressure area will be assessed and documented on the Treatment Administration Record (TAR) or the Wound Documentation Record. Document size, stage, site, depth, drainage, color, odor and treatment. When a pressure ulcer is identified additional interventions must be established and noted on the careplan in an effort to prevent worsening or re-occurring pressure ulcers.

Based on observation, interview and record review the facility failed to ensure the food products served were within the recommended date, failed to monitor food temperatures during meal service, failed to monitor temperatures and/or sanitizer level on dishwasher, failed to ensure to dishes were sanitized prior to resident use, failed to maintain sanitation practices in the facility kitchen, failed to monitor temperatures for the facility reach in cooler, reach in freezer, and chest freezer and failed to properly label and store foods. These failures have the potential to affect all 39 residents residing in facility. Findings include: The Facility Daily Census dated [DATE] documents 39 residents reside in facility. The facility Week four Sunday menu included Pot Roast and Vegetables, Harvard beets, roll/margarine and pie of choice. The facility was unable to provide temperature logs for the facility kitchen reach in refrigerator, reach in freezer, chest freezer and dishwasher. On [DATE] at 8:10 AM initial tour of the facility kitchen was completed with the following findings: 1. The facility large reach in freezer stored multiple large bags of frozen potatoes, waffles, waffle sticks and a plastic bag of pre-sliced unidentifiable pink deli meat which did not have any labels or expiration dates. 2. The facility large reach in refrigerator contained items with no label and no expiration date including: a clear plastic gallon sized container with an unknown red gel like substance, six deli sandwiches with meat substance and slice of yellow cheese, gallon sized clear container of mashed potatoes floating in hazy liquid on all sides/top and bottom, clear plastic bag of black crumbled substance and two whole cucumbers in clear plastic bag all with no label and no expiration date. 3. The facility large reach in refrigerator contained six quarts of lactose free milk all dated [DATE], multiple clear squeeze bottles of various condiments with no label and no date, a gallon sized mayonnaise container and buttermilk ranch dressing containers both with lids laying over top of open containers and neither had expiration dates or opened dates. 4. The air vents on the ceiling were filled with dust and brown grime. Occasional pieces of debris would float down from the ceiling vents onto the food prep area. 5. The facility reach in freezer is positioned directly next to the food holding table. The entire side of the facility freezer two feet deep by six feet tall was covered in unknown brown splatters and food debris. The food holding table does not have lighting over it. The area where the food holding table is located is very dim. 6. The facility food temperature log dated [DATE] did not have any entries for ,d+[DATE], ,d+[DATE] and ,d+[DATE]. 7. Dozens of small flying gnats were swarming an open bag of yellow onions in the dry storage room. One onion near bottom of the bag had a foul odor and was oozing brown liquid onto floor. 8. The facility small white chest freezer containing breadsticks, loaves of sliced bread and dinner rolls all with no label or expiration date did not have a thermometer inside the freezer. 9. The facility range hood located directly over the stovetop cooking area was covered with brown grime and grease splatters. The range hood had a sticker on it that read 'Range Hood Cleaning Inspection.' This same sticker has lines for dates to be written in for cleaning inspections. There were no dates filled in for dates of service. On [DATE] at 11:10 AM V14 Dietary Aide obtained a temperature of 105 degrees Fahrenheit during the wash cycle of the mechanical dishwasher. V14 then used a litmus strip to test the Ph level with a result of a faint purple line which correlated to less than 50 parts per million (PPM). V13 [NAME] observed the entire process. On [DATE] from 11:20 AM-1:30 PM V14 Dietary Aide and V13 [NAME] both used the dishwasher to wash holding pans, utensils, cups and covers for plates during meal service and then used the same dishes to serve resident foods during lunch service. On [DATE] at 8:40 AM V14 Dietary Aid stated (R23) gets that (lactose free milk). I used the carton that is sitting on the serving table (pointing at the same carton). (R23) gets it every morning. V14 Dietary Aide confirmed V14 served R14 expired lactose free milk. On [DATE] at 11:20 AM V14 Dietary Aide stated That dishwasher isn't running hot enough water and isn't cleaning the dishes like it should. I don't know what is wrong with it but the dishes still need done. V13 [NAME] stated That thing (dishwasher) didn't work right last week. I told them (facility) but nothing happened to it after that. Nothing got fixed. On [DATE] at 9:00 AM V5 Maintenance Director stated the facility has a contract with a cleaning company to clean the range hood. V5 stated I help to oversee the kitchen sometimes, so I know a lot about what goes on in there. We (facility) need a lot of help in that kitchen. It needs a deep clean for the entire kitchen. There are no cleaning schedules really. We (staff) just clean as we go or if we see something that needs cleaned, then we are supposed to clean it up. The contracted cleaning company comes once every five years to do a deep clean on the range hood. In between the five year mark there is no regular cleaning schedule. On [DATE] at 2:00 PM V1 Administrator stated the dietary staff should monitor the temperatures of the foods being served and stored. V1 stated the refrigerator, freezer, dishwasher and food temperatures should all be logged either daily or with each meal. V1 stated The kitchen needs a lot of work. I am not surprised there are issues. I know there have been logs in the past but I don't have anything now. I don't know if the staff are checking temperatures or not. I hope they are. V1 stated serving foods that are expired, not labeled or not temperature checked prior to serving could make a resident ill. The facility policy titled Kitchen Sanitation revised [DATE] documents the facility policy is to comply with local health standards and local and state sanitation regulations. The food service manager will develop a cleaning schedule for the department and ensure that the dietary employees complete cleaning tasks as scheduled. The facility policy titled Ware-Washing Dish Machine revised [DATE] documents for low temperature dish machines the temperature of the wash water shall not be less than 120 degrees Fahrenheit. Before washing anything, use a test strip to check the sanitizer level. For Chlorine sanitizers the level should be ,d+[DATE] parts per million (PPM). Record either the temperatures or the sanitizer level on the dishwasher temperature log.

Based on observation, interview, and record review the facility failed to ensure medications were labeled and stored appropriately in the medication storage room and medication cart. This has the potential to affect all 39 residents who reside in the facility. Findings Include: 1. R15's Physicians Orders dated September 2024 documents an order for a Combivent Inhaler 20mcg (micrograms)/100mcg (inhaler) one puff four times a day. On 09/23/24 at 11:55 AM, V9 LPN (Licensed Practical Nurse) administered a Combivent Inhaler 20mcg/100mcg to R15. This inhaler was loose in the medication cart and did not contain a pharmacy label with R15's name or instructions for use. At this time, V9 stated I don't know where the label is for the medication, but V9 knows the inhaler belongs to R15 because R15 is the only resident that gets Combivent. On 09/24/24 at 11:24 AM, V9 LPN administered a Combivent Inhaler 20mcg/100mcg to R15. This inhaler was loose in the medication cart and did not contain a pharmacy label with R15's name or instructions for use. At this time, V9 stated, I (V9) meant to get the pharmacy label in a bag with the inhaler but I forgot all about it. 2. On 09/25/24 between 10:20 AM and 10:41 AM, the medication refrigerator in the medication storage room had a silver padlock present on the refrigerator door but was not locked. Located in the medication refrigerator on the second shelf was a bottle of Lorazepam (antianxiety) {Controlled Substance} oral solution 2mg (milligram)/ml(milliliter) for R6 and a pharmacy metal box, unsecured in the refrigerator, with a pharmacy sheet indicating that the box contained Lorazepam 2mg/ml. On 09/25/24 at 10:37 AM, V3 ADON (Assistant Director of Nursing) stated the medication refrigerator should be locked at all times, and confirmed that it was not locked. V3 also stated the Lorazepam in the locked metal box could be used for any resident in the facility who would get an order for it. 3. On 9/25/24 at 10:39 am, the drawer labeled 25 and 26 of the treatment cart contained an opened bottle of Nystatin powder (Antifungal) without a label. On 09/25/24 at 10:41 AM, V1 (Facility Administrator) stated the Nystatin Powder would be for either R18, R9, or R1 however V1 did not believe that any of those residents had an order for Nystatin Powder. V1 then reviewed treatment orders for R18, R9 and R1 and confirmed neither of them had an order for the Nystatin Powder, therefore it should not be in the treatment cart. 4. On 09/25/24 at 11:02 AM, the top drawer of the medication cart contained the following: an open bottle of Azelastine HCL (Hydrochloride) 0.05% eye drops for R35 that was dispensed by pharmacy on 7/28/24 but did not document when the bottle was opened and an open bottle of Azelastine HCL 0.05% eye drops for R13 that was dispensed on 07/09/24 but did not document when the bottle was opened. On 9/25/24 at 11:10 AM, V3 Assistant Director of Nursing stated that eye drops should be dated when opened. The facility's Procurement and Storage of Medications policy reviewed 11/06/18 documents all medications brought into the Facility shall be labeled with at least the following information: Name, address and phone number of dispensing pharmacy; resident name, physician name, name and strength of medication, directions for administering, last date dispensed and prescription number; both the brand and generic name if substitution is made; appropriate auxiliary labeling. All medication containers shall be labeled with the date opened by the person breaking the container seal. Schedule II drugs are to be stored under double-lock subject to different key. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 09/22/24 documents 39 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to provide at least 80 square feet of floor space for each resident in resident bedrooms. This failure affects all 39 residents residing in the facility. Findings include: Historical room size documentation and actual measurements demonstrate the double occupancy resident bedrooms do not meet the minimum required square footage of 80 square feet per resident (160 total square feet) including Rooms 3-13, 14 (current Nursing Director Office), 16 (current therapy room), 17- 28 and 30. The Medicare/Medicaid Certification and Transmittal effective 8/22/23, from the most recent prior survey, documents all 58 resident beds are certified for Title 19 (Medicaid). The facility's Resident Census and Conditions of Residents form dated 9/22/24 documents 39 residents reside in the facility, all of whom reside in one of the double occupancy rooms. On 9/25/24 at 8:50 AM R12 was laying in her bed. R12 had a bed, dresser, walker, wheelchair and bedside table on her side of her room. R12 had multiple personal items on the dresser and on the floor. On 9/25/24 at 8:30 AM V5 Maintenance Director measured the square footage of rooms 11, 17 and 19 which all measured at 69.19 square foot total space for each resident, dual occupancy rooms. On 9/25/24 at 8:51 AM R12 stated This room is too small. We (R12 and roommate) both have a lot of things that we need to use every day. I have to move my wheelchair every time my roommate wants to use the bathroom because I don't have anywhere else to store my wheelchair when I am not using it. It is too cramped. On 9/25/24 at 8:25 AM V5 Maintenance Director stated None of the rooms in this facility meet the regulations. They are all too small. Some of the residents complain about it but there is not much we can do.

Based on interview and record review the facility failed to ensure it's antibiotic stewardship policy was comprehensive, and failed to track organisms and implement use of infection assessment tools. These failures have the potential to affect all 39 residents residing in the facility. Findings include: The facility provided Antibiotic Stewardship Program dated 12/10/21 documents to utilize core elements for antibiotic stewardship including accountability by identifying physicians, nursing, and pharmacy leadership responsible for oversight, action by implementing at least one policy/practice for antibiotic use, and tracking by monitoring at least one process measure and outcome. This policy does not document who is responsible for implementation and oversight of the program, what information should be tracked/monitored and the frequency, and what infection surveillance tools are used to ensure antibiotics are appropriately prescribed. The facility's Resident Infection Control and Antimicrobial Logs dated May-August 2024 document the following: R12 was prescribed different antibiotics on 4/26/24 and 5/22/24 for Urinary Tract Infection (UTI), but does not list the organism as prompted by the log. R27 was prescribed antibiotics on 5/23/24 for UTI and does not list the organism. R34 was prescribed different antibiotics on 6/11/24, 6/17/24, and 7/1/24 for other infection of urinary signs/symptoms, and a culture or infectious organism is not listed. R3 was prescribed different antibiotics on 7/20/24 and 8/16/24 for UTI, and a culture and organism are not listed. R190 was prescribed antibiotics on 8/3/24 for UTI, and a culture and organism are not listed. On 9/24/24 at 11:36 AM V1 Administrator/Infection Preventionist stated V8 Regional Clinical Director has been overseeing the infection control logs since the facility does not have a Director of Nursing. At 11:38 AM V8 stated the facility is ensuring appropriate symptoms for antibiotic usage and antibiotics aren't ordered until cultures are obtained as part of antibiotic stewardship. V8 stated the facility is only using McGreer Criteria (infection assessment tool) for UTIs and the AIM (Assess Intervene Monitor for wellness) communication forms document symptoms for other infections. V8 confirmed the infection logs do not document UTI cultures and resulting organisms after May 2024 and confirmed this is part of surveillance monitoring for infection control/antibiotic stewardship. On 9/24/24 at 12:18 PM V8 stated R34 kept having urinary symptoms despite a urinalysis that was negative for infection, and R34 has since been referred to a urologist. V8 reviewed the facility's Antibiotic Stewardship Program and confirmed it is not comprehensive to include who is responsible for oversight and implementation, what information is reviewed and the frequency, the use of cultures, and the use of any infection assessment tools. At 1:46 PM V8 stated V8 was unable to provide documentation that McGreer's Criteria or similar infection assessment tool was completed for R34, R3, and R190. On 9/25/24 at 10:03 AM V1 stated organisms should have been tracked on the infection control logs, and the Director of Nursing was responsible for doing that. The facility's Long Term Care Facility Application for Medicare and Medicaid dated 9/22/24 documents 39 residents reside in the facility.

Based on observation, interview and record review the facility failed to employ a full time Certified Dietary Manager. This failure has the potential to affect all 39 residents residing in the facility. Findings include: The Facility Daily Census dated 9/22/24 documents 39 residents reside in this facility, The Facility Assessment updated 7/15/24 documents the facility resources needed to provide competent support and care for the resident population every day and during emergencies includes a Certified Dietary Manager. On 9/22/4-9/25/24 during various times on first and second shifts there was no Certified Dietary Manager onsite during survey timeframe. On 9/22/24 at 8:25 AM V13 [NAME] stated the facility does not have a Dietary Manager. V13 stated It would be nice. There are so many things that need cleaned up, fixed and taken care of in our kitchen. That is the Dietary Manager's job to make sure we have the temperatures right, the residents get the right orders and make sure our kitchen runs smoothly. You can see that we (facility) need a lot of help. On 9/22/24 at 2:55 PM V1 Administrator stated the facility does not have a Certified/Dietary Manager. V1 stated the facility kitchen is overseen by V1 Administrator and V5 Maintenance Director. V1 stated We (facility) know our kitchen is struggling. There are new staff working in there with little to no guidance or training. We (facility) are working on that. We are working to make it better but it takes time. The errors in the kitchen may not have happened if we (facility) did have a Dietary Manager.

Based on observation, interview, and record review the facility failed to administer medications according to physician orders and manufacturer recommendations for four of 13 residents (R13, R24, R90, R31) reviewed for medication administration on the sample list of 34. The facility had five errors out of 26 opportunities resulting in a medication error rate of 19.23 percent. Findings include: 1.) R13's September 2024 Physician Order Sheet documents an order for Benztropine (Parkinson's medication) 2mg (milligram) three times daily with meals scheduled to be given at 12:00 PM and Novolin R (Fast Acting Insulin) 100 units sliding scale coverage according to R13's glucose level (151-200=two units, 201-250=four units, 251-300=six units, 301-350=8 units) scheduled to be given at 11:00 AM. On 09/23/24 at 11:17 AM, V18 LPN (Licensed Practical Nurse) stated V18 had already administered R13's oral medications before 11:00 AM, but is now ready to administer the ordered Insulin. V18 entered R13's room and checked R13's glucose level which read 199. On 09/23/24 at 11:21 AM, V18 withdrew 2 units of Novolin R Insulin out of a vial that was labeled with another resident's name and administered it to R13. At this time, V18 stated there was only one vial in the medication cart and it was the same Insulin that R13 uses so V18 administered that instead of going and getting R13's Insulin out of the refrigerator. On 09/23/24 at 12:21 PM, R13 was sitting in dining room waiting on lunch and stated he last ate at approximately 8:30 AM. On 09/25/24 at 1:00 PM, V1 (Administrator) stated Insulin should be given within 15 minutes of mealtimes and insulin vials should not be shared between residents. 2.) R24's September 2024 Physician Order Sheet documents an order for Ferrous Sulfate (Iron) 325mg three times daily with meals. On 09/23/24 at 11:34 AM, V18 LPN (Licensed Practical Nurse) administered R24's Ferrous Sulfate 325mg. On 09/23/24 at 12:21 PM, R24 was sitting in dining room waiting on lunch and stated he last ate at breakfast. 3.) R90's September 2024 Physician Order Sheet documents an order for Lispro (Fast Acting Insulin) 100 units sliding scale coverage according to glucose level scheduled to be given at 11:00 AM. On 09/23/24 at 11:40 AM, V18 LPN (Licensed Practical Nurse) entered R90's room and checked R90's glucose level which read 159. On 09/23/24 at 11:45 AM, V18 administered 5 units of Lispro Insulin to R90 according to R90's sliding scale order. On 09/23/24 at 12:18 PM, R90 was in his room waiting on lunch to be served. R90 stated he has had nothing to eat since breakfast, which was around 8:30 AM. On 09/25/24 at 1:00 PM, V1 (Administrator) stated Insulin should be given within 15 minutes of mealtimes. 4.) R31's September 2024 Physician Order Sheet documents an order to administer Lispro (Fast Acting Insulin) according to R31's glucose level, to be given at 11:00 AM. On 09/24/24 at 11:07 AM, V9 LPN (Licensed Practical Nurse) entered R31's room and checked R31's glucose level which read 212. On 09/24/24 at 11:13 AM, V9 administered 3 units of Lispro Insulin to R31 according to R31's sliding scale orders. On 09/24/24 at 11:19 AM, R31 stated she has not eaten anything since breakfast at 8:00 AM. On 09/24/24 at 11:49 AM, R31 was sitting in the dining room waiting on lunch to be served. On 09/25/24 at 1:00 PM, V1 (Administrator) stated Insulin should be given within 15 minutes of mealtimes. The package insert for Novolin R and Lispro Insulin dated February/2012 documents this fast acting insulin is to be administered within 30 minutes of the start of a meal.

Based on observation, interview and record review, the facility failed to store and secure portable oxygen cylinders appropriately for five of five residents (R27, R20, R5, R29 and R13) reviewed for oxygen on the sample list of 34. Findings Include: On 9/25/24 at 10:24 AM, there were three oxygen cylinders sitting on the floor in the medication storage room, not secured or in a cart, along with three oxygen carts that had three oxygen cylinders in them. At this time, V3 Assistant Director of Nursing confirmed that three oxygen cylinders were not secured in a cart and should be. V3 also stated that the oxygen cylinders should not be stored in the medication storage room and explained all oxygen is supposed to be stored outside. The facility's undated Residents On Oxygen form documents R27, R20, R5, R29 and R13 all use oxygen.

Based on observation, interview, and record review the facility failed to accurately complete resident assessments for four (R35, R36, R7, R27) of 12 residents reviewed for Minimum Data Sets (MDS) in the sample list of 34. Findings include: The facility's Comprehensive Assessments/MDS policy dated 11/1/17 documents the Resident Assessment Instrument should be utilized to comprehensively assess residents and to use resident observations and communications with the resident and staff to obtain resident information. 1.) R35's September 2024 Medication Administration Record documents R35 receives Xarelto (anticoagulant) 20 milligrams daily as of 2/1/24. R35's MDS dated [DATE] does not document anticoagulant use. On 9/24/24 at 12:40 PM V10 (MDS/Licensed Practical Nurse) stated V10 floats between three facilities as the MDS Coordinator and relies on V3 (Assistant Director of Nursing) to complete assessments that are related to the MDS coding. V10 stated V10 expects the assessments to be accurate since V10 does not really know the residents and their medical needs. V10 stated R35's MDS incorrectly documented antiplatelet use instead of anticoagulant. 2.) On 9/22/24 at 8:19 AM R36's Continuous Positive Airway Pressure (CPAP) mask and tubing was uncovered and on top of the CPAP machine on R36's night stand. R36 stated the nurses clean it and fill it with water. On 9/24/24 at 9:58 AM R36 stated R36 is not sure of the settings for R36's CPAP. R36 stated R36 uses the CPAP every night and just turns the machine on as the settings were previously preset. R36's September 2024 Physician Order Summary documents R36 has a diagnosis of Obstructive Sleep Apnea and R36 uses CPAP independently and the nurses are responsible for cleaning it weekly. R36's MDS dated [DATE] does not document CPAP use or R36's pulmonary disease. On 9/24/24 at 12:40 PM V10 stated V10 reviews physician orders for respiratory care needs such as oxygen and CPAP use. V10 confirmed R36's MDS does not document CPAP use. 32853 3.) R27's Physician's Order Sheet (POS) dated 9/1/24 through 9/30/24 documents diagnoses including Pacemaker, CVA (Cardiovascular Accident), A-Fib (Atrial Fibrillation) Respiratory Failure, OSA (Obstructive Sleep Apnea), COPD (Chronic Obstructive Pulmonary Disease), Asthma, Tachy-[NAME] Syndrome, Acute on Chronic Hypoxemic Respiratory Failure and COPD Exacerbation. This POS documents an order for Circuit mask and tubing, clean weekly on Sundays on day shift and order for CPAP (Continuous Positive Airway Pressure) on at night via mask IPAP (Inspiratory Positive Airway Pressure) at 12.0. R27's medical record documents that R27 was diagnosed with Pneumonia in June, 2024. On 9/22/24 at 8:45 AM, there was a CPAP machine on a cart on the left hand side of R27's bed. There was a mask and tubing attached to the machine. On 9/24/24 at 11:40 AM, R27 stated that she does have a CPAP machine but she states that it is missing parts so she hasn't been using it lately. R27's Minimum Data Sets dated 4/20/24 and 7/25/24 does not indicate that R27 uses a CPAP machine. The area Non-invasive Mechanical Ventilator CPAP is blacked out. On 9/24/24 at 12:17 PM, V10 Minimum Data Set Nurse confirmed that the CPAP was not coded on the MDS. V10 stated that it does not allow her to mark it as using while in facility for some reason. 4.) R7's Physician's Order Sheet dated 9/1/24 through 9/30/24 documents a diagnosis of Hemiparesis. On 9/22/24 at 9:35 AM, R7 was in his room in his wheel chair and his left hand was contracted. R7 raised his left arm up and tried to open his left hand and could only open slightly. R7's Minimum Data Set (MDS) dated [DATE] documents Range of Motion impairment to both sides of the body on the upper and lower portions. R7's Range of Motion assessment dated [DATE] documents R7 is at a moderate risk and documents that R7 has greater than 80% functional range of motion in his wrist, fingers and thumb of the left hand. R7's Range of Motion Assessments dated 1/4/24, 4/4/24 and 7/2/24 document R7 has full range of motion to his left wrist, thumb and fingers. R7's Functional Abilities and Goals Review dated 10/5/23, 1/4/24, 4/4/24 and 7/2/24 document R7 has no impairment his upper extremities. On 9/23/24 at 1:18 PM, V6 (Director of Rehab) confirmed R7 has a left hand contracture. On 9/24/24 at 10:18 AM V7 (Certified Nursing Assistant) confirmed that R7's left hand has been contracted since she has known him at least 1/1/2 years.

Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for three (R35, R36, R37) of 12 residents reviewed for care plans in the sample list of 34. Findings include: The facility's Comprehensive Care Planning policy dated 11/1/17 documents the facility shall complete periodic assessments for each resident which is used to develop the resident's person centered comprehensive plan of care, and this care plan should reflect medical and nursing needs. 1.) R35's September 2024 Physician Order Summary (POS) documents R35 receives Lurasidone (antipsychotic) 60 milligrams (mg) every morning and 80 mg every evening and Xarelto (anticoagulant) 20 mg daily. R35's Nursing Notes document the following: On 6/23/24 at 9:00 AM R35's thumb was bleeding from R35 biting his hand due to anxiety. On 7/9/24 at 3:00 PM R35 was biting his fingers due to anxiety/nerves. On 8/12/24 at 8:45 PM R35 had a verbal outburst related to wanting his medications. On 9/15/24 at 6:30 AM R35 banged R35's fists on the dining room table and cried wanting R35's medications. R35 yelled Give me them now. On 9/15/24 at 2:25 PM R35 demanded R35's scheduled 4:00 PM medications and yelled in the dining room. R35's Care Plan revised 9/23/24 documents anticoagulant use, antipsychotic use, behaviors of self harm and fixation on medications was not included in R35's plan of care prior to 9/23/24. On 9/23/24 at 1:25 PM V1 (Administrator) stated R35's anticoagulant and antipsychotic use should be care planned. At 1:47 PM V1 confirmed R35's self harm and fixation on medications should be care planned. 2.) On 9/22/24 at 8:19 AM R36's Continuous Positive Airway Pressure (CPAP) mask and tubing was uncovered and on top of the CPAP machine on R36's night stand. R36 stated the nurses clean it and fill it with water. On 9/23/24 at 10:04 AM R36's CPAP mask and tubing was uncovered and on top of the machine on R36's night stand. On 9/24/24 at 9:58 AM R36 stated R36 is not sure of the settings for R36's CPAP. R36 stated R36 uses the CPAP every night and just turns the machine on as the settings were previously preset. R36's September 2024 Physician Order Summary documents R36 uses CPAP independently and the nurses are responsible for cleaning it weekly. R36's Care Plan dated 5/20/24 does not document R36's CPAP use. On 9/23/24 at 12:20 PM V1 (Administrator) confirmed R36's care plan did not include CPAP use prior to 9/23/24. 50993 3.) R37's undated Facesheet documents R37 was admitted to the facility on [DATE]. R37's September 2024 Physician Order Sheet documents an order for Quetiapine (antipsychotic) 25mg (milligrams) in the morning and 50mg at bedtime. R37's Care Plan dated 08/14/2024 documents R37 uses an anti-psychotic medication related to diagnoses of Alzheimer's, end of life care, and anxiety. There is no specific behavior for the use of the antipsychotic, no appropriate diagnosis to justify the use of an antipsychotic medication, and no non-pharmacological interventions documented on the Care Plan. On 09/24/24 at 1:45 PM, V10 MDSC (Minimum Data Set Coordinator) stated R37's Care Plan dated 8/14/24 was the only Care Plan completed for R37. V10 stated Comprehensive Care Plans should be completed within 21 days of admission and confirmed that R37's was not completed during that timeline. V10 also stated that V10 only writes a basic Care Plan due to not knowing the residents well enough to do specific interventions due to working as MDSC in multiple facilities.

Based on interview and record review the facility failed to obtain a Level 2 Preadmission Screening and Resident Review (PASRR) after a new diagnosis of mental illness for one (R30) of three residents reviewed for PASRR in the sample list of 34. Findings include: R30's Face Sheet dated 8/26/24 comments R30 admitted to the facility on [DATE], a diagnosis of unspecified psychosis was added on 10/10/23, and a diagnosis of anxiety was added on 10/18/23. R30's Notice of PASRR Level 1 Screen Outcome dated 8/16/22 documents a Level 2 screening was not required since R30 did not have a mental illness diagnosis. There is no documentation that a Level 2 PASRR was completed after R30 was diagnosed with psychosis. On 9/23/24 at 10:47 AM V11 (Business Office Manager) confirmed V11 coordinates PASRRs. V11 reviewed R30's Level 1 PASRR and stated that a Level 2 was not required. V11 stated V11 has not had any residents with new diagnosis of mental illness after admission, so she was unaware that a Level 2 PASRR would be required. On 9/23/24 at 10:50 AM V18 (Licensed Practical Nurse) stated R30 has a history of behaviors of hallucinations and yelling out, but his behaviors have been better. V18 stated R30 self isolates since R30 has paranoia and anxiety when around a lot of people. V18 stated R30 sees (Psychiatry Services) and has had medication adjustments. On 9/23/24 at 12:40 PM V1 (Administrator) confirmed R30 has not had a Level 2 PASRR completed. V1 stated neither V1 nor V11 were aware that PASRRs needed to be done after a new diagnosis of mental illness.

Based on observation, interview and record review the facility failed to provide restorative care services for one of three residents (R7) reviewed for restorative services in the sample list of 34. Findings include: R7's Physician's Order Sheet dated 9/1/24 through 9/30/24 documents a diagnosis of Hemiparesis and documents an admitted [DATE]. R7's Minimum Data Set (MDS) dated [DATE] documents R7 had moderately impaired cognition and was not receiving any therapy or restorative services. R7's MDS dated [DATE] documents R7 is cognitively intact but did not receive any therapy and had 7 days of range of motion. On 9/22/24 at 9:35 AM, R7 was in his room and when asked if he had any concerns about his care he raised his left arm and tried to open his left hand. R7's left hand is contracted and he says that he thinks it just happened in the last couple months. R7 stated that he is not sure how it happened. R7 stated that he does not receive therapy or any exercises for his hand. R7's Restorative Nursing Program Documentation for August 2024 and September 2024 documents R7's restorative programs were to wheel himself in his wheelchair from the dining room to his room and for bilateral lower extremity exercises. There is no documentation that R7 has received any range of motion exercises for his left hand. On 9/23/24 at 1:18 PM, V6 Director of Rehab confirmed R7's left hand is contracted. She stated that R7's hand contracture was recently brought to her attention. V6 stated that she is waiting for orders to be signed for the therapy to begin. V6 stated that the last time R7 was on the case load his hand was not like that. V6 stated that she does not know what happened to it. V6 stated that she does not know the last time R7 had therapy services as it was a different therapy company and they do not have access to their records. V6 stated that she would assume they are doing range of motion exercises. V6 stated they will try to loosen that hand as much as possible and possibly try some splinting. V6 confirmed to her knowledge nothing has been done for the left hand contracture. On 9/24/24 at 10:18 AM, V7 Certified Nursing Assistant stated that R7's left hand has been contracted since she has known him at least 1 1/2 years. V7 stated that they have tried opening it and placing a wash cloth in it but he takes it out. V7 stated she tries to open it when washing and doing ADLs (Activities of Daily Living) and stretching but it goes right back contracted. V7 stated she does not know if there is any restorative program for R7's left hand. On 9/25/24 at 9:07 AM, R7 was in his wheelchair in his room with his left hand contracted and laying across his chest. On 9/25/24 at 10:16 AM, V3 Assistant Director of Nursing/RCC (Resident Care Coordinator) stated that staff should be doing range of motion exercises to R7's left hand.

Based on observation, interview and record review the facility failed to follow a physician order to provide a pureed diet by not providing the appropriate consistency of pureed foods for one (R14) out of one resident reviewed for diet consistency in a sample list of 34 residents. Findings include: R14's Cognitive assessment dated [DATE] documents R14 as moderately cognitively impaired. R14's Physician Order Sheet (POS) dated September 2024 documents R14's medical diagnoses of Hypertension, Dysarthria, Gastroesophageal Reflux Disorder (GERD) with Esophagitis, Cerebral Infarction, Hemiplegia and Hemiparesis. This same POS documents a physician ordered diet of Carbohydrate Controlled diet of pureed texture and thin liquids. R14's Careplan intervention dated 6/16/24 instructs staff to serve R14 his diet as ordered by Physician. The facility recipe for Pureed Pot Roast and Vegetables documents 2.0 servings of pot roast and vegetables should be mixed with one quarter cup of thickener. The facility recipe for Harvard Beets documents 2.0 servings of beets should be mixed with two tablespoons of thickener. The facility recipe for Bread/Toast/Roll documents 2.0 servings of bread should be mixed with two fluid ounces of milk and one and one-quarter teaspoon of thickener. On 9/22/24 at 11:43 AM V13 [NAME] added approximately two cups of pot roast with vegetables with 3.5 cups of tap water to blend to a pureed texture. The blended pot roast was pourable consistency with bits of meat. On 9/22/24 at 11:50 AM The blended pot roast lacked flavor, was not appealing to look at and had multiple pieces of meat that required mechanical chewing to break down. On 9/22/24 at 11:54 AM V13 [NAME] placed one serving of beets, one cup of water and three pumps of liquid thickener together to blend. The blended beets were very watery and pourable. On 9/22/24 at 12:45 PM R14 was served his pureed meal of pot roast, beets and breadsticks. R14 used a standard teaspoon to attempt to feed self. R14 had difficulty keeping his menu items on the spoon and spilled his pot roast, beets and bread on his lap. R14 took several bites of watery consistency foods served and began coughing. V17 Licensed Practical Nurse (LPN) walked over to R14, patted him on the back and asked if he was having trouble eating his meal due to the consistency was too thin. R14 continued to cough for 10 minutes. V17 LPN offered R14 drinks stating to R14 This will help clear your throat'. Your food is too thin for you. On 9/22/24 at 1:00 PM R14 stated That meal was too thin for me to eat. I spilled it all over me and what I did get down made me cough. I didn't choke or anything. I am not supposed to eat food that thin. On 9/22/24 at 1:30 PM V17 Licensed Practical Nurse (LPN) stated R14 has a history of difficulty swallowing and sometimes coughs during meals. V17 stated Our kitchen staff need to make sure (R14's) foods are at the right pureed consistency. Last week (R14) was served food so thick he was pocketing and coughing because he tried to swallow food that was so thick you could cut it. Today (R14's) meal is watery. We (facility) need to train our cooks how to prepare the resident's meals right before something really bad happens. On 9/22/24 at 2:30 PM V1 Administrator stated Our kitchen staff is fairly new. We (facility) are in the process of training them. (R14's) meals are supposed to be a pureed consistency which should be like pudding. Too thick or too thin (R14) could end up aspirating and get Pneumonia. The facility policy titled Therapeutic and Mechanically Altered Diets revised October 2020 documents the facility should prepare and serve all therapeutic and mechanically altered diets as planned. A therapeutic diet is a diet ordered to manage problematic health conditions. A mechanically altered diet is a diet specifically prepared to alter the consistency of food in order to facilitate oral intake.

Based on observation, interview and record review the facility failed to provide palatable foods for two (R14, R22) residents out of two residents reviewed for palatable foods in a sample list of 34 residents. Findings include: 1. R14's Cognitive assessment dated [DATE] documents R14 as moderately cognitively impaired. On 9/22/24 at 11:43 AM V13 [NAME] pureed R14's pot roast with vegetables, placed R14's blended pot roast in his divided plate and sat it on the counter for 55 minutes with no cover. R14's food was not warmed prior to serving at 12:38 PM. On 9/22/24 at 11:50 AM The blended pot roast lacked flavor, was not appealing to look at and had multiple pieces of meat that required mechanical chewing to break down. On 9/22/24 at 11:54 AM V13 [NAME] blended R14's serving of beets to a watery, pourable consistency. V13 then placed the entire portion of blended beets in R14's divided plate with the blended pot roast and set it back on the counter with no lid. On 9/22/24 at 12:20 PM V13 [NAME] mixed two breadsticks with 1.5 cups of water to blend to a watery, pourable consistency. The blended bread was light tan colored and had no flavor. V13 then added R14's blended bread to his partially made plate and returned R14's plate to the counter with no lid. On 9/22/24 at 1:05 PM R14 stated This food is so cold. I don't like cold food. 2. R22's Minimum Data Set (MDS) dated [DATE] documents R22 as cognitively intact. This same MDS documents R22 requires set up for eating. R22's Physician Order Sheet (POS) dated September 2024 documents a physician order for a regular consistency diet with thin liquids. On 9/22/24 at 9:00 AM R22 was laying in bed with her breakfast tray laying in front of her on her bedside table. On 9/22/24 at 9:03 AM R22 stated Our food is always cold. Look at this. They (staff) come in here and leave my tray but don't wake me up to eat or they wake me up but serve me cold food. I don't like cold oatmeal. It is nasty. I have asked them to reheat my food before but they never come back to do it. You don't have to take its temperature to know that it is too cold after its been sitting here for 45 minutes. On 9/24/24 at 2:50 PM V1 Administrator stated Resident's food should be warm to taste. We (facility) have ways to warm up the food if it is too cold but I know the staff might get busy and forget. The kitchen staff should not set food aside for an hour and then give it to the residents without warming it up first. I will provide education to the kitchen staff and Certified Nurse Aides (CNA) about making sure the meals are served warm. I don't know if we have a policy for this but it should just be the standard.

Based on observation, interview, and record review the facility failed to obtain consent, implement Gradual Dose Reductions, complete assessments, and track targeted behaviors for psychotropic medication use. These failures affect three (R21, R35, R37) of five residents reviewed for unnecessary medications in the sample list of 34. Findings include: The facility's Psychotropic Medication Policy dated 11/28/17 documents attempt to rule out causes of behaviors, attempt non-pharmacological interventions, initiate a Pre-Psychotropic Medication Assessment prior to starting a new psychotropic medication, complete Psychotropic Medication Assessments within 14 days of admission and at least quarterly, obtain informed consent, and document behaviors on the behavior tracking sheets. This policy documents residents receiving psychotropic medications will have either a psychiatric diagnosis or maladaptive behaviors that could be harmful to themselves/others, cause emotional distress, or destruction of property. This policy documents gradual dose reductions (GDR) will be attempted at least twice per year unless clinically contraindication is documented by the physician, the pharmacy will request GDRs as needed on a monthly basis, these recommendations will be sent to the physician in a timely manner and the nurses will transcribe the physician's recommendations once received. 1.) R21's Minimum Data Set (MDS) dated [DATE] documents R21 has severe cognitive impairment, R21 has verbal behaviors towards others, R21 takes an antipsychotic, a GDR has not been attempted since the last assessment and there is no physician documented clinical contraindication for a GDR. R21's September 2024 Physician Order Summary (POS) documents the following orders: a referral to (Psychiatry Services) 9/16/24, Divalproex (mood stabilizer) Sodium Extended Release (ER) 250 milligrams (mg) give two tablets every morning and three tablets every evening 5/26/23, Risperidone (antipsychotic) 0.25 mg daily five times per week 1/14/20, and Mirtazapine (antidepressants) 7.5 mg daily 1/18/22. This POS documents R21's diagnoses include Dementia, Alcohol Abuse, and Bipolar Disorder. There are no documented consents for Risperidone or Mirtazapine in R21's medical record. There is no documentation of attempted GDRs for Divalproex, Risperidone, and Mirtazapine within the last year in R21's medical record, or physician documented clinical rational as to why GDRs should not be implemented. On 9/24/24 at 11:16 AM V8 Regional Clinical Director provided R21's psychotropic medication consents, which only documented consent for Divalproex. On 9/25/24 at 9:20 AM V1 Administrator stated V1 can't locate R21's August 2024 pharmacy recommendation that was in R21's medical record. V1 stated she recalls seeing it, and it should not have been sent to (Psychiatry Services). V1 confirmed R21 had not been seen by (Psychiatry Services) prior to the order 9/16/24. V1 stated GDR requests and physician declination are documented on the pharmacy recommendations. V1 confirmed September 2024 pharmacy recommendations have not been returned from the physicians yet. V1 stated all of R21's psychotropic medication consents have been provided. On 9/25/24 at 9:45 AM V1 Administrator provided R21's pharmacy recommendations dated 4/3/24, 5/1/24, 8/1/24, and 9/4/24, all of which are blank/incomplete. The pharmacy Consultation Reports dated 4/3/24, 5/1/24, 8/1/24 and 9/4/24 document R21 receives Risperidone 0.25 mg five times weekly, Depakote (Divalproex) ER 500 mg every morning and 750 mg every evening, and Mirtazapine 7.5 mg every evening for Bipolar Depression and to consider a GDR. These reports suggest reducing Risperidone 0.25 mg to every other evening. These forms are incomplete and do not document the recommendation was followed up with R21's physician. On 9/25/24 at 10:00 AM V3 Assistant Director of Nursing stated pharmacy recommendations are sent from pharmacy to V1, V1 then gives the forms to the nurses to send to the physician for follow up and implement the orders. V3 stated the completed forms are given back to V1. On 9/25/24 at 10:03 AM V1 stated V1 would look to see if R21's pharmacy recommendations were completed, if they weren't completed there would be repeat GDR requests. The facility failed to provide documentation that these pharmacy recommendations were implemented. 2.) On 9/22/24 at 9:05 AM R35 stated R35 does not see a psychiatrist, only his primary physician. On 9/23/24 at 10:30 AM R35 was participating in BINGO activity and loudly asked when R35 was going to get R35's medications. V9 Licensed Practical Nurse (LPN) told R35 that V18 LPN was doing something first and then V18 would administer R35's medications. R35's Face Sheet dated 8/26/24 documents R35 admitted on [DATE] and R35's diagnoses include Panic Disorder, Schizophrenia, and Major Depressive Disorder. R35's MDS dated [DATE] documents R35 has moderate cognitive impairment, R35 refuses cares and wanders, R35 takes an antipsychotic, a GDR has not been attempted since the last assessment and there is no physician documented clinical contraindication for a GDR. R35's September 2024 POS documents the following orders: Lurasidone (antipsychotic) Hydrochloride 60 mg every morning and 80 mg every evening 2/1/24, Buspirone (antianxiety)10 mg twice daily 2/1/24, Hydroxyzine (used for anxiety) 25 mg twice daily 7/20/24, and Trazodone (antidepressant) Hydrochloride 100 mg daily. There are no documented consents for these psychotropic medications and no documented psychotropic medication assessments for the use of Hydroxyzine in R35's medical record. R35's July and August 2024 Medication Administration Records document Hydroxyzine 25 mg twice daily PRN (as needed) was initiated on 7/19/24. This medication was given nine times prior to being scheduled twice daily on 8/14/24. R35's Nursing Notes document the following: On 6/23/24 at 9:00 AM R35's thumb was bleeding from R35 biting his hand due to anxiety. On 7/9/24 at 3:00 PM R35 was biting his fingers due to anxiety/nerves. Between 8/7 and 8/10/24 R35 was given Hydroxyzine as needed for anxiety. On 8/12/24 at 8:45 PM R35 had a verbal outburst related to wanting his medications. On 9/15/24 at 6:30 AM R35 banged R35's fists on the dining room table and cried wanting R35's medications. R35 yelled Give me them now. On 9/15/24 at 2:25 PM R35 demanded R35's scheduled 4:00 PM medications and yelled in the dining room. R35's August 2024 and September 2024 Behavior Tracking does not include R35's behaviors of biting his hands/fingers or fixation on medications. Crying is the only documented targeted behavior on these tracking forms. The pharmacy Consultation Reports dated 8/1/24 and 9/4/24 document R35 has received Lurasidone 60 mg every morning and 80 mg every evening and Trazodone 100 mg every evening since 2/1/24 and documents to attempt a GDR for these medications and to consider implementing a GDR. These forms document to consider decreasing Lurasidone to 60 mg twice daily. These forms are incomplete and do not document the recommendation was followed up with R35's physician. The 8/1/24 report included a handwritten note that this form was sent to (Psychiatry Services) for review. On 9/22/24 at 10:50 AM V17 LPN stated R35 has Schizophrenia and has not received any psychiatric services after admitting to the facility. V17 stated last week V17 requested that R35 be evaluated by (Psychiatric Services) and the facility was in the process of getting R35 a guardian at that time. V17 stated R35 would benefit from psychiatry services due to R35's behaviors of crying and temper tantrums when R35 does not get his way. On 9/23/24 at 1:44 PM V18 LPN stated R35's behaviors consist of self harm by biting his thumb until it bleeds if he doesn't get his way, fixating and frequently asking about his medications, and R35 charged at V18 the other day. On 9/23/24 at 1:25 PM V1 Administrator stated R35 has not had psychiatric services since admission and will be seeing (Psychiatry Services) next visit. V1 stated the facility recently initiated obtaining a guardian for R35, but prior to that we were obtaining medication consents from R35 since R35's Brief Interview for Mental Status Score is high enough. V35 stated psychotropic medication assessments should be documented quarterly, with significant changes, upon initiation, and with increases in dosages. V1 stated these assessments are documented in the assessment section of the medical record. V1 verified R35's medical record did not contain assessments for Hydroxyzine. V1 stated V1 will see if V1 could find consents for R35's medications. V1 stated the facility has not gotten the September 2024 pharmacy recommendations back yet from the physicians. V1 confirmed R35's August pharmacy recommendation was not signed by a provider and V1 thinks the form was sent to (Psychiatry Services) by mistake. On 9/23/24 at 1:47 PM V1 confirmed R35's self harming behaviors and tantrum behaviors should be included in R35's behavior tracking. V1 stated V1 thinks V4 Social Services Director misinterpreted that when V4 documented crying behaviors on R35's behavior tracking. On 9/24/24 at 3:11 PM V1 stated V1 was unable to locate R35's psychotropic medication consents and assessments for Hydroxyzine. 50993 3.) R37's undated Facesheet documents R37 was admitted to the facility on [DATE]. R37's Physician's Orders dated September 2024 document R37 was admitted to the facility with the following orders: Quetiapine (antipsychotic) 25mg (milligrams) in the morning and 50mg at bedtime and Mirtazapine (antidepressant) 45mg at bedtime. These Physician Orders also document an order received on 8/18/24 for Lorazepam (antianxiety) 1mg twice daily and every 4 hours as needed. R37's medical record does not contain a consent for any psychotropic medications. R37's medical record documents a GDR (Gradual Dose Reduction) for Quetiapine to be reduced to 25mg BID (twice daily) that was declined on 07/18/24 by V20 (Hospice Medical Director), but no justification/rationale was provided for the decline. R37's medical record only contained one Psychotropic Medication Evaluation dated 07/03/2024. This document is not complete and does not document indications for use or resident specific behaviors. On 09/24/2024 at 1:15 PM, V1 (Facility Administrator) stated no psychotropic drug reviews are done on admission, only quarterly, and explained I (V1) didn't know we (facility) were suppose to do them on admission. V1 stated no consents for the psychotropic medications were completed for R37.

Based on observation, interview, and record review the facility failed to obtain orders for Continuous Positive Airway Pressure (CPAP) settings and maintain hygienic care and storage of CPAP equipment for one (R36) of two residents reviewed for CPAP in the sample list of 34. Findings include: The facility's Bilevel Positive Airway Pressure/CPAP policy dated 3/8/13 documents CPAP and BiPAP use must have orders that includes the type of unit, pressure settings, inspiratory/expiratory positive airway pressure, frequency, oxygen if applicable, and humidification if applicable; and to clean the circuits weekly and as needed. 1.) On 9/22/24 at 8:19 AM R36's CPAP mask and tubing was uncovered and on top of the CPAP machine on R36's night stand. R36 stated the nurses clean it and fill it with water. On 9/23/24 at 10:04 AM R36's CPAP mask and tubing were uncovered and on top of the machine on R36's night stand. On 9/24/24 at 9:58 AM R36 stated R36 is not sure of the settings for R36's CPAP. R36 stated R36 uses the CPAP every night and just turns the machine on as the settings were previously preset. R36's September 2024 Physician Order Summary documents R36 uses CPAP independently and the nurses are responsible for cleaning it weekly. There is no order for the settings or airway pressure for R36's CPAP. On 9/23/24 at 10:06 AM V18 Licensed Practical Nurse stated R36 is independent with CPAP care, but the night nurses clean it between 5:00 AM and 6:00 AM. V18 stated the CPAP mask should be stored in a clear plastic bag when not in use. On 9/24/24 at 9:46 AM V1 Administrator confirmed R36's orders should include settings and airway pressure. V1 stated R36 does a lot of things independently, but doesn't always know things medically. V1 stated V1 will follow up to see what R36's CPAP settings should be.

Based on interview and record review the facility failed to report an allegation of physical abuse to the Abuse Coordinator for one of one resident (R4) reviewed for abuse in a sample list of 34 residents. Findings include: The facility policy titled 'Abuse Prevention Program' revised 11/28/2016 documents the facility affirms the right of the residents to be free from abuse, neglect, misappropriation of property and exploitation. Abuse is the willful injection of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This same policy documents the facility must ensure all allegations of abuse are reported immediately to the Administrator of the facility. The report must be made to Illinois Department of Public Health (IDPH) within 24 hours after forming the suspicion. R4's undated Medical Diagnosis List documents medical diagnoses of Psychotic and Mood Disturbance, Anxiety, Congestive Heart Failure, Bipolar without psychotic features, Dementia with Agitation, Schizophrenia and Weakness. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as moderately cognitively impaired. This same MDS documents R4 requires moderate assistance with dressing, eating, personal hygiene, bathing, toileting and transfers. R4's Nurse Progress Note dated 9/17/24 at 4:00 AM documents (R4) complained '[NAME] cut my privates.' (R4) reoriented to surroundings and escorted for safety. No further behavior noted. R4's Initial Report to the State Agency dated 9/22/24 documents (R4) made a statement that someone named '[NAME]' cut her private parts. No one in the facility with that name. On 9/22/24 at 1:30 PM V1 Administrator stated V1 was never notified of R4's allegation. V1 Administrator stated I am just now seeing this nurse progress note. I didn't know anything about it. We (facility) do not have a resident or staff member named [NAME]. (R4) has a lot of behaviors like Hallucinations and Delusions. There was no indication that (R4) ever had anything like that happen. The staff did assess her with no findings but just did not report it to me. I will get that reported to the State Agency right away.

Based on observation, interview, and record review the facility failed to ensure equipment is in good working repair, and the environment is clean and free of debris for three (R25, R26, R6) of 12 residents reviewed for safe homelike environment out of a sample list of 34. Findings include: The facility's 11/2018 Resident Right's policy provided by V1 (Administrator) documents the facility must provide a safe, clean, comfortable and homelike environment. 1.) On 9/23/24 at 1:30 PM, R25 stated his dresser in his room is broken and missing the front of his top dresser drawer. R25 stated he made staff aware a week ago, but nobody has fixed his dresser yet. R25 stated since his dresser has been broken it has become harder to get to his items he needs. On 9/23/24 at 1:38 PM, the face to the top drawer of R25's dresser was missing. The floor of this drawer was broken in half. R25's clothes from the top drawer were falling out of the drawer and into the next dresser drawer. These clothes included socks and underwear. On 9/23/23 at 1:50 PM, V5 (Maintenance Director) stated that's an issue. V5 confirmed at this time that R25's dresser should be in good working repair. 2.) On 9/25/24 at 10:05 AM, R26's bed was unmade. The top of the mattress had large, dark, brown, and black discolorations covering eighty percent of the mattress. The mattress was indented and broken down in the middle. On 9/25/24 at 10:10 AM, V12 (Housekeeper) stated R26's mattress always looks that way and V12 does her best to clean the mattress but the stains are permanent. V12 stated I wouldn't want my family member on that mattress. V12 further stated that many mattresses in the facility are in bad shape and need replaced. 32853 3.) R6's Physician's Order Sheet dated 9/1/24 through 9/30/24 documents diagnoses including Unspecified Dementia, Cerebral Infarction and Altered Mental Status. R6's Minimum Data Set (MDS) dated [DATE] documents R6 requires assistance to roll from left to right and back in bed and documents that R6 is dependent for transfers from the bed to the chair. On 9/22/24 at 8:36 AM, R6 was not in his room but the bilateral side rails were up and there was foam wrapped around and taped to the side rails. The foam was ripped and the tape was shredded and frayed. On 9/22/24 at 12:57 PM the side rails were in the same condition. On 9/22/24 at 9:39 AM, R6 was in his room in his wheel chair. R6 was yelling for someone to help him up and he had his hand on the side rail shaking it and rattling it back and forth. On 9/24/24 at 2:44 PM, V5 Maintenance Supervisor confirmed R6's side rails are in poor condition and look bad. V5 stated that he has new foam and tape in the garage that he can replace R6's with.

Based on interview and record review the facility failed to implement effective interventions to prevent falls with injury for one (R1) of three residents reviewed for falls in the sample list of three. This failure resulted in R1 falling and sustaining a fractured left hip. Findings include: R1's diagnoses include: Alzheimer's Disease, Dementia, Gastroesophageal Reflux Disease, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Chronic Kidney Disease, Pulmonary Disease, Hypothyroidism, Atherosclerosis, Heart Disease, Hypertension, Anxiety Disorder, Cardiomyopathy, Left Hip Replacement, Anemia, Vitamin D Deficiency, Right Eye Blindness, Periodontal Disease, Falls, Nicotine Dependence and a History of Alcohol Abuse. R1's undated face sheet documents R1 admitted to the facility on [DATE]. R1's Fall assessment dated [DATE] documents R1 as at high risk for falls. R1's March physician orders document an order for Plavix (blood thinner) 75 milligrams daily. R1's Minimum Data Set, dated dated dated [DATE] documents R1 as severely cognitively impaired. R1's Behavior Tracking Record dated March 2024 (1st-29th) documents a goal that R1 will not attempt to transfer R1's self without staff supervision/assist, with an intervention of keep in supervised areas while up in wheelchair. R1's fall care plan dated 1/18/24 documents that R1 is to be reminded to lock wheel chair brakes, keep call light in reach, and of safety precautions and limitations as needed. R1's progress notes dated 3/17/24 document that at 9:50PM, R1 was found on the floor in the facility sunroom, in front of his wheel chair. R1's progress notes document on 3/18/24 at 10:00AM, R1 was sent to the emergency room due to continued pain and tenderness to R1's left leg and thigh. R1's hospital history and physical dated 3/18/24 documents a fall that resulted in the fracture of R1's left hip and a subdural hematoma that could not be delineated as subacute or chronic. R1's medical record documents the result of R1's fall on 3/17/24 was a left hip fracture requiring toe touch weight bearing of the left lower extremity, two assist with transfers, physical and occupational therapy and pain management post fall. R1's facility fall investigation documents that R1 fell as a result of not having the awareness to be safe due to lack of cognition. On 4/3/24 at 10:22PM, V7 RN (Registered Nurse) said R1 stands up and tries to walk all of the time and because of his dementia doesn't have safety awareness. On 4/4/24 at 12:15PM, V11CNA (Certified Nurses Assistant) stated R1 tries to get up a lot and that they have to keep him up in the evenings so that he doesn't try to get up and fall. On 4/4/24 at 1:17PM, V12 CNA stated R1 tries to stand up from his wheel chair all the time. On 4/4/24 at 2:34PM, V3 Licensed Practical Nurse said he thought R1 was in bed when he fell on [DATE] and that R1 often tries to stand up from his wheel chair. V3 said, We usually hear him when he's wanting to get up but in that sunroom with the television, we can't hear anything. On 4/4/24 at 12:15PM, V11 Certified Nursing Assistant (CNA) stated she was at the nurse's station but that R1 wasn't within view.

Based on interview and record review the facility failed to provide pain control and failed to transfer a resident with a broken femur to the hospital in a timely manner for one (R1) of three residents reviewed for falls in the sample list of three. This failure resulted in R1 remaining in the facility for ten hours while in pain with a broken left femur before being transferred to the hospital for pain control and care. Findings include: R1's diagnoses include: Alzheimer's Disease, Dementia, Gastroesophageal Reflux Disease, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Chronic Kidney Disease, Pulmonary Disease, Hypothyroidism, Atherosclerosis, Heart Disease, Hypertension, Anxiety Disorder, Cardiomyopathy, Left Hip Replacement, Anemia, Vitamin D Deficiency, Right Eye Blindness, Periodontal Disease, Falls, Nicotine Dependence and a History of Alcohol Abuse. R1's Minimum Data Set, dated dated dated [DATE] documents R1 as severely cognitively impaired. R1's Fall assessment dated [DATE] documents R1 as a high risk for falls. R1's care plan dated 3/20/24 documents recent fracture related to a fall. R1's medical record documents R1's blood pressures on the following dates: 167/82 on 2/10/24, 154/88 on 2/11/24, 137/74 on 2/15/24, 112/67 on 2/16/24 and 138/74 on 3/17/24. R1's hospital history and physical dated 3/18/24 at 1:53PM documents a left femur fracture as a result of the fall of 3/17/24 and an initial blood pressure of 189/85 with a pulse rate of 78. R1's progress notes document the following: On 3/17/24 at 9:50PM, R1 was found on the floor in the facility sunroom, in front of his wheel chair. On 3/18/24 at 1:00AM, R1 was heard yelling, Help me, help me, while complaining of pain, guarding his left leg, and he could not straighten out his left leg. On 3/18/24 at 3:30AM, R1 continues to yell out in pain from both hips. R1 was then removed from the bed and placed in a wheel chair. On 3/18/24 at 8:30AM, R1 continues to complain of hip pain, is unable to bear weight or lift his leg without pain. At this time, V8 Licensed Practical Nurse (LPN) documents a request for a portable X-ray of R1's left hip. On 3/18/24 at 10:00AM, R1 was sent to the emergency room due to continued pain and tenderness to R1's left leg and thigh at the request of V10, R1's family member. R1's March Medication Administration Record documents one administration of Tylenol 1000 milligrams (mg) on 3/18/24 at 1:00AM. R1's hospital discharge date d 3/2024 documents the decision by orthopedics to watch fracture and provide pain control with Tramadol (opioid pain medication) 50 milligrams (mg) ordered every six hours as needed for pain and Tylenol 650mg ordered every six hours as needed for pain. On 4/3/24 at 11:43AM, V10 R1's Family Member said that when she arrived at the hospital, R1 was moaning in pain. On 4/3/24 at 10:22PM, V7 RN stated, When I came on shift that night, (R1) didn't complain of pain. About 1:00AM, he was yelling Help me, so I helped him use his urinal and noticed that he was guarding his left leg, hip and thigh. That didn't seem like it was from a hip injury, so I gave him Tylenol and that seemed to settle him down. At about 3:30AM, he was yelling again and complaining of bilateral hip pain and grabbing his left thigh. I still didn't really think that it was his hip, so we got him out of bed, and he complained of pain when we transferred him, but then when he was sitting in the chair, he seemed ok. Around 4:45AM, he was sitting at the nurse's station and said that he was tired, but he didn't want to go back to bed. Later on, I thought about his dementia and probably should have sent him sooner. On 4/3/24 at 10:45AM, V6 Resident Care Coordinator (RCC) said she was notified when R1 fell and was told that he had no pain or obvious signs of injury. The next morning, V6 RCC was notified that R1 had pain all night and that V7 Registered Nurse had tried to call her to discuss it. V6 said, I told (V7 RN) that he knew that R1 had a fall and the first time that he complained of pain, he should have used his nursing judgement and have sent (R1) out. (R1) was hurt by the pain. On 4/3/24 at 2:20PM, V13 Medical Director said he was notified of the fall, but not of the pain until the next morning when (R1) was sent to the hospital. V13 said, The pain could have been controlled and hours of pain prevented if they had sent him sooner. A higher blood pressure can be indicative of a person experiencing pain. The facility pain policy dated 12/7/17 documents it is the policy of the facility to assess for, reduce the incidence and the severity of pain in an effort to minimize further health problems, maximize activity of daily living functioning and enhance quality of life.

Based on observation, interview, and record review the facility failed to investigate repeated allegations of sexual and physical abuse of R1 by an employee and failed to prevent potential further abuse by failing to remove the alleged perpetrator (V4, Registered Nurse) from direct resident care for one (R1) of six residents reviewed for sexual abuse on the sample list of seven. These failures resulted in the alleged perpetrator having direct contact with R1 for ten more days in a two-week time period. During this time R1 continued to make daily allegations of physical and sexual abuse against V4, was scared for her safety, was unable to sleep, and felt like no one was listening to her. This failure had the potential to affect all 36 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 10/27/22, the facility remained out of compliance at a Severity Level 2 while the facility continues to: provide weekly in-servicing regarding the importance of reporting all abuse allegations to the Administrator, conduct 1:1s (one to one supervision) with R1 to ensure resident's safety, conduct interviews with residents and staff to ensure safety and that no abuse has occurred, and review plans and actions during daily Quality Assurance meetings to ensure compliance. Findings include: R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Cognitive assessment dated [DATE] documents R1 has moderately impaired cognition. On 10/22/22 at 10:15 AM, R1 was lying in bed. R1 sat straight up in bed and stated, I have been sexually abused here. A little short guy (V4) who runs the place, he tried to abuse me sexually. I don't want anything to do with him. He is a short guy with a long ponytail. R1 then began to get tears in her eyes and stated, I have been upset and no one will listen to me. I can't sleep. He is in and out all the time. He tried to rape me and he tried to put his hands in me. I kicked him off me and he tried to sexually rape me. His name is (V4's name) but I don't know him. It happened in my room. I woke up and realized I was being attacked. I can't even sleep. I have a heart condition and cancer. I came here to get rehab. It happened to me twice. Both times happened while I was in the bed. The other men and everyone else have been most polite. Maybe he has a hard time because he is short and ugly. I have seen him on the floor since and he was passing medications. I don't feel safe at all here with him running around. I will fight for my life and kill him if I have to. On 10/24/22 at 9:40 AM, V18 Hospice Nurse stated R1 accused a male nurse (V4) of touching her. V18 stated V18 did report it to the facility and her guardian (V19). V18 stated the first time he reported it was on 10/4/22. V18 stated she says something about (V4) every time I come in and she is very upset when she is talking to me. V18 stated (R1) says (V4) will come in and touch (R1). V18 stated V18 reports it to the nurse on duty every visit. V18 stated (R1) also accused (V4) him of throwing (R1) down in the bed, that was on 10/14/22. V18 stated the facility has called (V18) to come in and sit with (R1). V18 stated (R1) fears (V4). R1's nurse's note dated 10/6/22 at 11:00 AM, written by V8 Licensed Practical Nurse (LPN) documents, Resident (R1) very upset, stated a white male fought with her and touched her last night and she was scared to be alone. On 10/22/22 at 9:17 AM, V8 stated, About two weeks ago, (R1) was in the dining room and I asked her why she was out there. She told me she had a scuffle with some white man and she said some white man did something to me. She said, Well I'm not going to allow him to do anything else to me. She said it happened down there at the hotel. I thought down there at the hotel was her room. She was saying it was last night but (V4) was not working. I did tell Administration. I was trying to figure out what she was talking about. I felt like (V4) was the only one she could be talking about. On 10/22/22 at 8:40 AM, V11 Activity Aide stated, (R1) tells me about it every time I see her. She brings it up. I talked to other folks (staff) about it. She says that (V4) came into her room and he put his hands on her and tried to rape her and she fought him off. I do one on ones with her when she will allow it so I see her about every day. I asked if they could put a baby monitor in her room to see what was going on because something must have happened. She says he is short and her story is always the same. It's all she wants to talk about. She is scared and upset. She hasn't accused any of the other staff of anything like that. On 10/22/22 at 8:30 AM, V4 Registered Nurse stated: he has never touched R1 except to walk her down the hallway. He is the 3rd shift nurse. She does get medication because she is on hospice. I give her a pill at midnight. It is [MEDICATION(S)]. I now have one of the Certified Nurse's Assistants (CNA) accompany me when I work with her. Because I am the only nurse, I do have to interact with her. I have no clue why she made this allegation. She was confused one night and she was walking down the hall without her walker and she was wearing a top for sure so I approached her and I took her to the dining room. I got the (unknown) CNAs attention. She ended up having a [CONDITION(S)] (Urinary Tract Infection). That's when her behavior toward me changed. She gets very suspicious now about me. She is still angry towards me and I don't know what I did to offend her. When I work, she will ask others where am I at and will ask why am I here. She is very suspicious towards me. She will yell out when she sees me, That's him, that's you, call the police! Then her story will change. She had an accident where she fell in the bathroom. And I don't think she was clothed then. I had to go in and assess her when she fell . I believe there was a (unknown) CNA in there when I assessed. She wasn't hurt when she fell . I believe the management is aware that she is still accusatory towards me. On 10/22/22 at 9:43 AM, V1 Administrator stated V1 has not conducted an investigation of abuse related to R1's allegations against V4. V1 has not removed V4 from having further contact with R1 and has not notified the police or the state agency after the allegations of abuse were made. V1 stated they chalked it up to R1's having behaviors or delusions. V1 stated this is the first time she has made allegations of a sexual nature. V1 stated R1 says stuff daily and that she is now fixated on V4. V1 stated this started at the beginning of October 2022. On 10/24/22 at 9:59 AM, V17 Regional Director of Operations stated when there is an allegation of any type of sexual misconduct then the alleged perpetrator should be suspended pending investigation, the Administrator, the guardian, police, and public health should be notified. The facility's Daily Census dated 10/22/22 provided by V1 Administrator documents there are 36 residents residing in the facility. An Immediate Jeopardy situation was identified on 10/25/22. The Immediate Jeopardy situation was identified to have begun on 10/4/22 when the facility failed to recognize and investigate an allegation of sexual abuse (against V4) and remove the alleged perpetrator from direct contact with R1. On 10/25/22 at 4:00 PM, V1 Administrator was notified of the Immediate Jeopardy Situation. On 10/26/22 between 7:45 AM and 4:00 PM, the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: 1.) On 10/25/22 the V17 Regional Director of Operations in serviced (re-educated) the Administrator on the Abuse policy and the importance of reporting to the required agencies, doing a thorough investigation on all allegations/incidents and removing alleged perpetrators immediately pending the investigation. 2.) All staff in-serviced on Abuse Policy on October 5th and will do random weekly in-servicing regarding the importance of reporting all abuse allegations to Administrator. Inservice conducted by V1 Administrator and V2 Resident Care Coordinator on 10/25/22. 3.) V1 Administrator and V21 Social Service Director will conduct 1:1 with R1 daily Monday through Friday times two weeks to ensure residents safety. V21 initiated this on 10/26/22. 4.) On October 22, 2022, V4 Registered Nurse was immediately suspended upon Administrator being notified of allegation. 5.) Residents at the facility were interviewed regarding their safety and care at the facility with no concerns noted. Completed by V12 CNA Supervisor on 10/26/22. 6.) V1, Administrator will conduct interviews with residents and staff three times a week for four weeks to ensure safety and no abuse has occurred. V1 initiated this on 10/26/22. 7.) Plan and actions will be reviewed during daily QA (Quality Assurance) meetings to ensure compliance to deter reoccurrence. Initiated on 10/27/22 and lead by V1 Administrator. 8.) V4 remains suspended pending outcome of investigation. V4 remains suspended as of 10/27/22 per V1, Administrator.

Based on record review, observation and interview the facility failed to perform timely incontinence care to prevent shearing over R28's bilateral ischium (pressure ulcers), continued to implement nursing order while waiting for physician to be notified for a pressure ulcer treatment for two newly, facility acquired, Stage II pressure ulcers (shearing over bony prominence) 7/2/22-7/27/22 (25 days) and failed to measure the new, worsening pressure ulcers in accordance with facility policy for R28. These failures affected R28 and resulted in avoidable Stage II pressure ulcers with deterioration of the pressure ulcer as evidence by an increase in size. The facility also failed to ensure pressure relief device was in working order for R9. R9 and R28 are two of three residents reviewed for pressure ulcers on the sample list of 21. Findings include: 1. R28's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The same POS does not have a treatment order documented until 7/27/22. (Pressure ulcer were identified 7/1/22 as documented below). R28's Minimum Data Set (MDS) dated [DATE] (same day pressure ulcers discovered) documents the following: R28's Brief Interview of Mental status score was 10 out of a possible 15 indicating moderate cognitive impairment. The same MDS documents R28 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The same MDS documents R28 is always incontinent of bladder and frequently incontinent of bowel and has had no behaviors of rejecting care. The same MDS documents R28 is dependent on total physical assistant of two staff for hygiene needs and requires extensive assistance of one staff with toileting and transfers. R28s Care Plan dated 5/12/22 documents the following: P (Problem) High Risk for Pressure Ulcers per (Formal) Risk Assessment. (Formal) Risk score of 13 on 5/12/22. Risk factors Include bladder incontinence, history of pressure ulcers to left fourth toe, healed January 2015. Resident Specific Information: Requires assistance with toileting, bathing, dressing, needing reminders and physical assistance. G. (Goal) Will have no open areas caused by pressure or friction for the next review. A (action to be implemented) Apply house stock (Brand name) to peri-area with every (sic)after incontinent episode and as needed. Toilet/change brief when wet and upon rising, hs (bedtime) and after meals. The same Care Plan documents the following: P (Problem) Alteration in bladder elimination as related to incontinence. G (Goal) Skin will remain intact thru (through) next review. A (action to be implemented) Toilet and/or change padding and give proper hygiene before/after meals, upon rising, upon request, before retiring for the evening, after napping, and prn (as needed) for incontinence. R28's (Formal) scale for predicting pressure ulcer risk date 7/1/22 (the same date as the MDS look back assessment) documents R28 is at high risk for level for developing pressure ulcers. 07/24/22 at 10:05 am R28 stated I (R28) have sores on my (R28's) bottom from not getting changed often enough. R28 also stated The night staff got me (R28) up (out of bed) and dressed between 5:00 am - 6:00 am. I (R28) have not been changed (provided incontinence care) since. R28 also stated R28 incontinence brief is very wet at this time and has soaked through R28's pants. On 7/24/22 at 10:12 am V11, Certified Nursing Assistant (CNA) stated R28 was already up and dressed when V11, CNA came in to work at 6:00 am. V11, CNA stated (R28) usually gets up around 4:00 am, but I (V11, CNA) am not sure what time night shift (staff) changed (provided incontinence care) (R28). (R28) has not been changed since I (V11, CNA) came in at 6:00 am. I have been very busy. On 7/24/22 at 10:25 pm R28 had wheeled R28's wheelchair to the hall bathroom door. V11, CNA assisted R28 assisted to a standing position. R28's sweat pants were visibly saturated across the full seat of R28's pants. R28's incontinence brief was totally saturated, hanging down between her legs to mid-thigh, and dripped with urine onto R28's bilateral legs and the floor. V11, CNA removed R28's saturated incontinence brief. R28 stated Oh my sores hurt so bad. R28 did not have a treatment dressing on either of two Stage II pressure ulcers at the back of her thigh/buttock fold. R28 had two nickel sized open areas of shearing over the bony prominence, (Stage II pressure ulcers), one on each upper inner thigh crease, ischial region. Both areas were red and raw in appearance. R28's buttocks and thigh skin were deeply indented and red. V11, CNA stated Usually (in general) those open areas have a wound dressing on them. R28 asked V11, CNA if V11, CNA would put some cream on the areas because they 'hurt so bad.' V11, CNA could not find a barrier cream to apply to R28's open wounds. V11, CNA stated to R28 All I can do is get you washed up. You don't have any cream (barrier). I will make sure you are clean and dry and that will fill better (relieve pressure ulcer pain). R28's A.I.M for Wellness nursing note dated 7/1/22 documented by V7, Licensed Practical Nurse (LPN) documents the following: Assess; This change in condition, symptoms, or signs observed and evaluated are MASD (Moisture-Associated Skin Damage) to bilat (bilateral) back thighs. This started on 7/1/22. This condition, symptom, or sign has occurred before (blank checked) Yes. Other relevant information: Is at risk for skin breakdown per (formal skin evaluation). The same AIM for Wellness nursing note documents the following: ' (Number) 7. Skin Evaluation, Contusion (bruise) check marked, Other MASD to back bilat (bilateral) thighs. (Number) 8. Pain Evaluation; Does the resident have pain? (checked) Yes. Is the pain new (checked) Yes. Description /location of pain; While performing peri-care (incontinence care). Intensity of pain (rate on scale of 1-10, with 10 being the worst): 5 (moderate). The same AIM for Wellness nursing note documents the following: Manage; Physician recommendations and /or nursing interventions, Assist c (with) toileting q (every) 2 (two) hours and prn (as needed) and toileting hygiene. Assist c (with) T and P (turning and repositioning) while in bed and wheelchair q two hours and prn. Implement physician ordered treatment. V7, LPN also provided a hand written pressure ulcer plan of care for additional interventions dated 7/1/22. The hand written plan documents: P (problem).) Resident (R19) has 2 (two), Stage 2 (two) pressure injuries on posterior thighs. G (goal). Residents wounds will heal and no new skin issues by next review. (first bullet) Start 7/1/22 nsg (nursing) A (action to be implemented).) Apply ordered TX (treatment)- see POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (bullet number 10) Start 7/1/22 nsg A. Daily skin (check mark) c (with) documentation and prn with any new skin issues. On 7/26/22 at 9:30 am V7, Licensed Practical Nurse (LPN) reviewed a quality assurance document and stated she can give me the information from the document but is not allowed by the corporation to give a copy to the surveyors. V7, LPN stated I can tell you what happened, I was the nurse that found (R28's) shear wounds from (R28's) excessive incontinence on 7/1/22. (R28's) skin breakdown was obvious (obviously) from being so wet. I was helping (not sure which it was) CNA's with resident care. I cleansed (R28) peri-area. (R28) had two areas, very irritated and open. (R28's) Left, back inner thigh open area (identified below on plan of care as Stage II) measured 1.2 centimeter (cm) long by 0.2 cm wide, and superficial so depth could not be measured. (R28's) second open area (identified below on plan of care as Stage II) to her right, inner back thigh open wound measured 1.3 cm long by 0.4 cm long and the depth was superficial and could not be measured. I (V7, LPN) cleaned them with Theraworx (wound cleaner), applied skin prep around the outside of the wounds and put [MEDICATION(S)] dressings on them to prevent further destruction of the tissue. I did this as a nursing judgment and faxed (facsimile) the doctor for actual orders (physician). I notified the family and (V1, Administrator in Training), we don't have a DON (Director of Nursing who is required to be notified of new pressure ulcers). I faxed the orders to (V23, Physician) and reported off to the next shift nurse. I can't remember which one (nurse). I thought they (nurses) would follow-up and get an order (physician, pressure ulcer treatment order). I didn't put (document) the treatment (V7, LPN implemented as a nursing judgement) on (R28's) POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (R28) has a history of skin breakdown, MASD (Moisture-Associated Skin Damage) the cause. I (V7, LPN) educated the CNA's (unidentified) on turning and repositioning resident (R28), and proper timely incontinence care. R28's Treatment Administration Record (TAR) dated 7/1/22-7/31/22 documents R28 was not provided weekly skin assessments 7/11/22, and 7/25/22. R28's same TAR documents on 7/4/22, R28's had redness to buttocks and groin, on 7/8/22, R28 had irritation at an unidentified location, and on 7/18/22, R28 had redness and/or irritation in the groin area. On the same TAR there are no measurements documented of R28's bilateral, posterior thigh pressure ulcers (identified 7/1/22) until 7/27/22. The same TAR does not document the following treatment was completed until 7/27/22. The treatment order documents: R28's Bilateral thigh had shearing related to Moisture-associated Skin Damage, clean area with (name brand wound cleaner) and apply [MEDICATION(S)] dressing, every three days and as needed. The back of the same TAR documents measurements were obtained on 7/27/22 as follows: Left, posterior med (medial) thigh, shearing (Stage II, shearing over bony prominence) related to MASD, measured 1.4 cm long, by 0.2 cm wide, by 0 cm, (increased from 7/1/22 Stage II measurement of left, posterior thigh 1.2 cm long by 0.2 cm wide by 0 cm depth). Right, posterior med (medial) thigh, shearing (Stage II, shearing over bony prominence) related to MASD, measured 3.0 cm long, by 0.4 cm wide, by 0 cm, (increased from 7/1/22 Stage II measurement of right, posterior thigh 1.3 cm long by 0.4 cm long by 0 cm depth). In comparison to the only measurements obtained prior to 7/27/22, from the quality assurance document 7/1/22 mentioned above, and reviewed by V7, LPN, R28's left thigh pressure ulcer increased by .2 cm in length, and R28's right thigh pressure ulcer increased by 1.7 cm in length. On 7/26/22 at 1:55 pm V17, Medical Director/Physician (MD) stated V17, MD expects all incontinent resident to receive timely incontinence care. MASD (Moisture-associated skin damage) causes skin breakdown. V17 also stated V17, MD was not informed (R28) had open areas caused by MASD. V17, MD stated V17, MD should have been informed. A treatment order would have been given. V17, MD also stated the [MEDICATION(S)] dressing applied by the V7, LPN that found the open areas was appropriate and should have been continued to prevent further breakdown. V17, MD also stated R2's incontinence saturation observed, and no dressings on the open wounds after R28 complained of being wet for hours, Absolutely, caused the added pain, pressure ulcers and possibly further skin impairment. 2. On 7/25/22 at 12:10 PM, multiple scarred areas were present on R9's buttocks. R9 stated she used to have sores on her bottom. R9 stated that her bed deflates frequently and she has told the staff about it and that they taped the hose. R9 stated that the bed was semi-deflated now. The mattress was about halfway deflated when touched. Duct tape was taped around the middle of the air mattress hose and at the connection to the air mattress pump. On 7/25/22 at 11:26 AM, V14 Hospice Nurse stated that R9 has the air mattress to prevent pressure ulcers. V14 stated the air mattress hose should not be taped. V14 stated the facility should have called and notified her that the air mattress was not working so that it could be replaced. R9's Baseline care plan dated 5/16/22 documents R9 is at high risk for pressure ulcers.

Based on observation, interview and record review the facility failed to lower R19's bed after providing cares and left R19 unattended in an elevated bed by resulting in a fall with serious injury and failed to complete neurological assessments for R19's fall. This failure resulted in R19 sustaining a fracture of the left wrist. R19 is one of three residents reviewed for falls on the sample list of 21. Findings include: R19's Face Sheet dated 6/30/17 documents the following diagnoses: Guillain-Barre syndrome, Paraneoplastic Neuromyopathy and [CONDITION(S)], Muscle Weakness Generalized, and Unsteadiness on Feet. R19's Physician Order Sheet (POS) dated July 1-31, 2022 documents the following: Continue to wear splint, make appointment with (Private Hospital) 7/9/22. R19's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status score of 15 out of a possible 15, (no cognitive impairment). The same MDS documents R19 has limited range of motion in one upper extremity, and bilateral lower extremities. The same MDS documents R19 is totally dependent on two staff for transfers and bed mobility. R19's Care Plan dated 6/26/22 documents the following: (R19) will use bed rail for repositioning at every opportunity thru (through) next review. Bed in lowest position. The same Care Plan documents: (R19) rolled out of bed, alleged fall. Fall mat placed, ed (education) given to (R19) and staff (unidentified) on bed in the lowest position. On 07/24/22 at 10:48 am, R19 was seated in R19's wheel chair next to R19's bed. R19 had a splint on the left wrist. R19 stated the following: All is good here except, I fell out of my bed about a month ago (6/26/22) and fractured my (left) wrist. I had to wait several days before the facility would get an X-ray (second X-ray). I don't think I would have broke my wrist if the bed was in a lower position. It was high like it is now. (R19 points to the elevated bed. R19's bed was three and a half feet above the floor). I (R19) fell far and hard. They were worried about my head. I am hard headed. It (R19's head) didn't hurt but I kept telling them my left wrist hurt and I wanted an X-ray (completed 6/27/22 and 7/8/22). I should have put on my call light and waited for staff to turn me. I thought I could adjust my position in bed on my own. Obviously, I won't do that again. R19's A.I.M. (Assess, Intercommunicate, Manage) for Wellness (nurses note) dated 6/26/22 (Sunday), signed by V6, Regional Director of Clinical Operations, documents the following: Alleged fall. The same AIMS for Wellness note documents the following; Manage, Physician recommendations and/or nursing interventions. X-Ray to L (left) wrist, may wait till Monday d/t (due to) patient (R19) request of not wanting to leave the facility and wait till Monday (6/27/22). Fall mat placed, and resident and staff educated on bed in lowest position. There was no documentation of neurological assessments noted on the AIM note or in the Nurse Notes after R19's unwitnessed fall. R19's X-ray report dated 7/8/22 was ordered by V17, Medical Director documents the following: Reason: Swelling, pain with movement post fall (6/26/22). The same report documents Left wrist, two views. Findings; see impressions. Impression: Acute distal ulnar fracture. R19's Illinois Department of Public Health (IDPH), Final report (initial report 7/8/22 after second X-ray) dated 7/14/22 documents the following: (R19) Rolled out of bed and landed on her arm. It was not fractured at the time of the incident but was later determined that her wrist was fractured. The same IDPH report documents: Staff Interview: (V20, Certified Nursing Assistant) CNA, I had laid resident (R19) down to use the bathroom, when I went back a few minutes later she (R19) was on the floor. I put a pillow under her head and the other CNA (V22) went to get the nurse (unidentified). On 7/26/22 at 9:55 am V7, Licensed Practical Nurse (LPN)/ Minimum Data Set Coordinator stated V7, LPN was the nurse that cared for R19 the day of R19's fall on 6/26/22. V7, LPN stated the fall was not witnessed. V7, LPN also stated I should have initiated neurological assessment according to the policy, but I did not. V7, LPN stated (V20, Certified Nursing Assistant/CNA) was the CNA that worked that day. I re-educated (V20, CNA) to lower the resident beds after providing resident care so, this kind of thing doesn't happen to anybody else. I had noticed (R19's) bed was too high, immediately when I did her assessment (6/26/22). V7, LPN also stated When (R19) fell , (R19) complained of serious left arm pain. I can't remember if I gave her Tylenol, but I think I gave it (Tylenol). V7, LPN also stated (V17, MD) gave and order that day for x-ray that showed no fracture. It was about six days later that (R19) continued to complain of wrist pain and another X-ray was done. The second (X-ray) did show a fracture (left wrist). (R19) only had a skin tear the day of the fall from her bed. There was no swelling. I wanted to send (R19) to the hospital but (R19) refused. (R19) said she was ok and did not hit her head. I am pretty sure I gave Tylenol for the pain. On 7/26/22 at 2:10 pm V17, Medical Director stated the height of R19's bed should have been in the lowest position. The elevated height of the bed would increase the impact during the fall and was the likely the cause of R19's wrist fracture. V17, Medical Director also stated R19's fall was unwitnessed, therefore neurological assessments should have been ongoing as our policy documents. The facility policy Fall Prevention dated December 2009 documents the following: Policy: To provide for resident safety and minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Responsibility: All staff. Procedure: (Number 5). Immediately after any resident fall the unit nurse will assess the resident and provide any care and treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. Number 6. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an AIM for Wellness form along with any new interventions deemed appropriate at the time. The unit nurse will also place any new interventions on the CNA assignment worksheet. The same Fall Prevention policy documents the following: Fall Prevention Interventions: (Number 10.) Bed in lowest position-wheels locked. The facility policy Head Injury: dated reviewed 12/22/17 documents the following: It is the policy of (Private Corporation) to evaluate head injuries for a minimum period of 72 hours, to determine any negative effects, and to allow for immediate treatment to minimize permanent damage.

Based on interview and record review, the facility failed to ensure R2 was not subjected to physical and verbal abuse by another resident, R1. R1 and R2 are two of four residents reviewed for abuse in the sample list of 10. This failure resulted in R2 expressing fear and trauma related to physical and verbal altercations with R1. R2 has expressed fear of coming into contact with R1 and this limits R2's movement about the facility, including not leaving R2's bedroom and not participating in dining activities where R1 is present. Findings include: The facility's Final Report dated 4/18/22 documents on 4/11/22, R1 and R2 were involved in a physical altercation. This report documents R1 recently admitted to the facility on [DATE] and is alert and oriented. R2 was admitted to the facility 9/20/17 and is alert and oriented. This report documents R2 reported to V5, Licensed Practical Nurse (LPN) that R1, R2's roommate bit R2 after R2 went to R1's side of the room to talk to R1 because R1 was throwing things at R2's television. This report documents R1 stated R1 bit R2 because R2 attacked and jumped on R1. R1 stated R1 was lying in R1's bed when R2 jumped on R1 and R2 attempted to cover R1's nose and mouth. R1stated R1 bit R2 in self-defense. This report documents several alert and oriented residents were interviewed and stated no concerns or recollections of (R2) being physically aggressive with anyone. This report documents V3, Resident Aide stated R2 approached V3 in the hall stating that R1 bit R2's right hand. V3 reported the incident to V5. V5's interview in this report documents R1 and R2 were immediately separated and moved to different rooms and placed on 1:1 supervision. R2 was placed on 15 minute visuals upon return from the hospital. R1's Baseline Care Plan dated 4/11/22 document R1 ambulates with a rolling walker with supervision. This Care Plan documents on 4/12/22, R1 was placed on 15 minute checks and had a room change after altercation with R2 on 4/11/22 for identified safety risks: safety plan of care. R1's 15 minute monitoring sheets begin with the date of 4/17/22 and are ongoing. These sheets do not document 15 minute monitoring for 4/24/22 or 5/2/22. R1's Nurse's Notes document as follows: 4/11/22 at 9:00pm documents R1 was in room in bed and got into an altercation with roommate (R2) that became physical. R1 defended R1's self by biting R2 when R2 jumped on top of R1. R2 put R2's hand over R1's mouth as if R2 was trying to smother R1. R1's fingernail on right hand, third finger was ripped off during the altercation (1/2 way). R1's finger had minimal bleeding and no pain but did request PRN Anxiety medication. 4/13/22 4:00pm, R1 was seen in the hall having a verbal altercation with another resident. Staff immediately intervened and separated the two. On 4/28/22 at 3:00pm, R1 stated, yeah, I bit (R2), I (R1) sure did! R1 stated R1 had a tight bite on R2's hand and was not letting go if R1 could help it and continued to bite R2's hand after R2 had fallen to the floor. R1 stated R2 tried to beat R1 up twice and had jumped on (R1) and flipped out. R1 stated a few days later after the first incident, R2 saw (R1) coming and confronted (R1). R1 stated R2 tried to push R1 and V13, Dietary Manager saw the whole thing and told R1 that R1 didn't do anything. R2's Nurses Notes dated 4/13/22 at 4:00pm document R2 was in the hall having a verbal altercation with another unidentified resident and staff intervened and separated the residents. On 4/28/22 at 2:40pm, R2 stated soon after R1 was admitted to the facility , R1 was mad about R2's television but could not remember if it was the volume or channel. R2 stated one evening, R1 was throwing stuff at R2's television so R2 went to find a staff member to talk to R1. R2 stated after R2 found V5, Licensed Practical Nurse (LPN) and told V5 what was going on with R1, R2 went back to the room. R1 continued to throw stuff at R2's television so R2 went to R1's side of the room as R1 was lying in bed and R2 attempted to remove items from R1's hands so R1 would stop. R2 stated R1 grabbed R2's hand and chomped down and bit R2's right hand and would not let go of R2's hand. R2 stated R1 hit R2 and R2's glasses flew off and R2 fell to the floor while R1 continued to clench R1's teeth on R2's hand. R2 stated R2 had to yank R2's hand out of R1's mouth as R2 was on the floor. At this time, R2's right hand was noted to have a small open puncture wound to under the right thumb. R2 stated R2's right hand was swollen, bruised, painful and had teeth marks and the skin was broken. R2 stated the incident was very traumatic for R2. R2 stated not even a week later R1 rammed in to R2 with R1's walker in the hall while R2 was ambulating. R2 didn't know R1 was behind R2 at the time. R2 stated V12, Dietary Manager came to help. R2 stated R2 turned around and asked R1, why did you bang (run/hit) into me, quit banging into me. R2 stated when R2 attempts to leave R2's room, R2 checks around for R1 and if R1 is in the dining room or where R2 is headed, R2 goes back to R2's room in attempt to avoid R1. R2 stated R2 is afraid of (R1) and that R2 does not trust R1. On 5/3/22 at 9:40am V13, Physical Therapy Assistant (PTA) stated R1 and R2 were maybe about 10 feet from each other on 4/13/22 in the hall when V13 first looked down the hall while assisting with therapy. V13 looked up again and looked down the hall and observed R1 run in to R2 from behind with R1's walker. R2 turned around and asked why R1 hit R2 with R1's walker. The verbal altercation began to escalate. R1 went to pick up R1's walker and swing it toward R2 after the incident but I am unsure if contact was actually made. R1 and R2 were arguing and exchanging words. Their tone was not nice, and neither were their words. V13 stated V13 called for assistance when R1 and R2 began to escalate and R1 picked up walker and began swinging it toward R2. On 5/2/22 at 1:25pm, V12, Dietary Manager stated R1 antagonizes and starts the situations. R1 was calling R2 slurs including b**** during an altercation in the hall. V12 stated R1 likes using the word retard and was calling R2 a retard at that time in the hall as well. V12 stated R2 was walking down the hall toward R2's room, not facing the direction of R1 and R1 was behind R2. V12 stated R2 has told V12 R1 is worried about coming out to dining room when R1 is here and R1 stating that crazy b**** (R1) is gonna jump me (R2.) On 5/2/22 at 3:00pm, V1 (Administrator) stated V1 was notified that R1 and R2 literally physically hurt each other at 8:08pm on 4/11/22. R2 showed V2 (DON) R2's finger where the nail had been ripped off. V1 stated R1 has never had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 stated the facility did not send R1 out for psychiatric evaluation, but R2 had been. R1 had a broken fingernail, not too severe. V1 stated R2 had marks from where R1 bit R2 on R2's hand and that the emergency room had cleaned the wound. V1 stated V1 was told R2 had teeth marks from R1 biting R2. V1 stated the physical abuse between R1 and R2 on 4/11/22 was substantiated. V1 stated on 4/13/22, R2 was in front of R1 and R2 was heading to toward R2's room and R1 bumped into R2, (V1) think by accident. R2 turned around and said something to R1. V13, Physical Therapy Assistant (PTA) reported R1 and R2 bumped into each other and were having a verbal altercation. V1 stated it wasn't really anything but V13 wanted to make sure V13 reported it to the facility.

Based on interview and record review, the facility failed to supervise residents (R1 and R2) with a known history of inappropriate sexual behavior to prevent resident to resident sexual abuse. This failure resulted in R2 being sexually abused by R1. Staff allowed R1 and R2 to go unsupervised with unrestricted access to each other resulting in sexual behaviors between two residents who are unable to consent, exposing them to abuse. This failure affects two (R1, R2) of residents reviewed for abuse in the sample list of 12 residents. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 10/5/21 at 10:25am, onsite observation, interview and record review verified the facility is in the process of training staff, including re-education on the facility abuse policy and monitoring R1 and R2. The facility remains out of compliance at a severity level two. Findings include: R1's Physician's Notes dated 4/9/21, documents R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This note documents R1 had been hospitalized and was evaluated while in the hospital and felt to be incompetent. R1's Brief Interview for Mental Status dated 7/19/21 documents R1 is severely cognitively impaired. R2's Care Plans dated 1/14/2013, document R2 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . These Care Plans also document R2 has a history of inappropriate display of sexual behavior related to R2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 9/5/21 11:15 am, R1's Progress Notes document R1 was found next to R2 in a recliner. This note documents V3, Licensed Practical Nurse (LPN) observed R1 attempting to put (R1's) hands on (R2) inappropriately. V3 intervened and separated R1 and R2. V3 notified V16 Regional Director (RD). This note documents will continue to monitor (R1) and keep separate from females. The facility's interview dated 9/9/21 with V3, documents resident incident and that V3 overheard another staff (unidentified) saying R1 had sat in recliner with R2. When V3 investigated, (V3) saw R1 trying to place R1's hands inside R2's pants, grabbing R2's waistband and trying to put (R1's) fingers in. 9/5/21 11:49am, fax notification sheet to V7 (Physician) documents Another resident (R1) attempted to sexually inappropriate touch (R2)., there was no further interventions documented. R1's Progress Notes dated 9/5/21 7:40pm document, on 9/5/21 at 5:30pm, V4 (Registered Nurse - RN) responded to a call light that was sounding. V4 and V5 (Certified Nursing Assistant - CNA) walked into the room and observed R2 laying on R2's back on a bed with R2's pants down. This note documents R2's feet were in front of R2's vaginal area. R2 was laying the wrong way, positioned across the bed with R2's head toward the wall. R1 had R1's pants down and turned around when V4 and V5 entered the room. R1 saw V4 and V5 and pulled up R1's pants and started to exit the room. V5 escorted R1 out of the room. V4 assisted R2 to get R2's pants pulled up and walked (R2) out of the room. This note also documents both R1 and R2 have Dementia and wander throughout the facility. R2 is unable to communicate. (R2) didn't look like anything had occurred because there were no sign of body fluids, etc. R1's Hospital emergency room physician notes dated 9/5/21, document R1 is oriented to person only, ambulates to the bathroom and is up in the room without difficulty. This note documents R1 was found standing in a female resident's (unidentified) room with no clothes on. On 9/21/21 at 2:15pm, V4 Registered Nurse (RN) stated V4 was the nurse on duty on 9/5/21 and was one of the staff members to answer the call light and observe the inappropriate sexual behavior. V4 stated V4 felt R1 knew what (R1) was doing because as soon as V4 and V5 answered the call light and found R1 and R2 with their pants down in the room, R1 immediately pulled R1's brief and pants up and began to leave the room. V4 stated R1 was fixated on R2 for a couple of days following the incident. V4 stated V4 found R1 holding R2's hand in the dining room as V4 documented on 9/7/21. This was two days after R1 and R2 were found in the room with no clothing on from the waist down. V4 stated R1 and R2 were behind V4 when V4 turned around and witnessed the hand holding. V4 stated R2 could not have removed/taken R2's pants down by R2's self. V4 stated R2 had the call light in one of R2's hands but could not recall which hand, which was odd because R2 doesn't know how to use the call light. V4 stated when V4 came in to work that day (9/5/21) around 2:00pm, during report with the nurse (V4 could not remember who the nurse was) it was mentioned something had happened and everyone was notified that needed to be. V4 could not remember what V4 was told that had happened. Regarding the 9/5/21 5:30 pm incident, V4 stated R2's feet were propped up on the bed with knees bent upward and R1 was standing right in front of R2. V4 stated V4 spoke with the local police department to report the sexual abuse incident. V4 stated R1 and R2 were at the bed that is closest to the door of the room with R2 laying on R2's back. R2's body was across the bed against the wall with head by wall. R1 and R2 both had their pants and briefs down, exposing themselves to each other. V4 stated V4 assisted R2 to pull R2's brief and pants up. V4 stated V5 escorted R1 out of the room. V4 was unsure of when R1 and R2 were last observed together. V4 did not know where R1 was taken when V5 escorted R1 out of the room. V4 stated staff mentioned when R2 was first admitted to the facility, that R2 had promiscuous behaviors and residents would take advantage of that. V4 stated that on 9/6/21 R1 kept circling R2 and was fixated on R2. On 9/23/21 at 10:10am, V12 (Housekeeper) stated V12 observed R1 dipping (R2's) hand in (R1's) pants. V12 stated R1 kept trying to put R1's hands in/down the front of R2's pants multiple times. V12 stated R1's hand was down (R2's pants) enough to R1's knuckles and was trying to push down further in to R2's pants. V12 stated V12 had not been contacted by V1 (Administrator in Training - AIT) for an interview regarding the incident on 9/5/21. V12 stated R1 was purposefully touching R2 in a sexually inappropriate way and R2 would not be able to consent or know what was happening. On 9/23/21 at 12:05pm, V15 (Cook) stated V15 came out of kitchen on 9/5/21 (unsure of what time) and saw R1 sitting next to R2 with R1's arm around R2 and leaning in to (R2). V15 stated V15 told staff standing there, you know how (R1) is and you better get (R1), that is not right. V15 stated R1 and R2 are not cognitively aware to make those decisions. V15 stated some staff thought it was cute. V15 stated when V3 (LPN) responded, R1 was trying to put R1's hands down R2's pants. V15 stated V15 was not contacted for a witness interview related to R1 and R2's sexual inappropriateness on 9/5/21 at 11:15am. R1's Pharmacy Consultation Report dated 9/10/21, documents R1 has experienced an increase in unusual behavior patterns (resident to resident sexual behaviors and inappropriate remarks). An Immediate Jeopardy situation was identified on 09/27/21 at 3:33pm. The Immediate Jeopardy was identified to have begun on 9/5/21 at 11:15am, when R1 was observed touching R2 in a sexually inappropriate way. R1 and R2 were not kept separated/supervised. On 9/5/21 at 5:30pm, R1 and R2 were found in the room of other residents, both with pants down, exposing their lower bodies, perineal areas to one another. R2 was on the bed laying across the bed with buttocks toward the outer edge of the bed and head to the wall with R1 standing in front of R2. On 09/27/21 at 3:33pm, V16 Regional Director (RD) was notified of the Immediate Jeopardy situation. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the immediate jeopardy: 1.) On 9/27/21, V16 Regional Director (RD) in-serviced V1 Administrator in Training (AIT) on the Abuse Prohibition Policy and the importance of completing a thorough investigation on all allegations/incidents. V1 also received education regarding the importance of ensuring 1:1 supervision and 15-minute visual checks are carried out and documented. 2.) On 10/5/21 at 10:25am, V1 provided documentation that additional in-servicing on the facility's Abuse policy was initiated on 10/5/21. The facility will complete random weekly in-services on the facility Abuse policy and the importance of ensuring residents receive 1:1 supervision or 15-minute checks that require are required. There is no documentation of this being completed after 9/25/21 as of 10/4/21. 3.) Social Services (SS) and Activities departments have increased their sessions with R1 and R2, working with R1 and R2 separately. Per V1, V24 (Social Services) stated V24 was unable to complete the number of sessions (3 sessions weekly) as documented in the facility's abatement plan. There is no documentation that V9 (Activities Director) has increased R1 or R2's activity sessions since 9/27/21. The facility is working with V9 as to where those sessions can be documented. 4.) On 10/4/21 at 11:00am, V1 provided updated documentation that the Interdisciplinary Team (IDT) reviewed residents involved in resident-to-resident abuse allegations to ensure resident specific targeted behaviors have appropriate person-centered interventions. 5.) On 9/27/21 the IDT was in-serviced by V16 (Regional Director) to review residents for changes in behaviors to investigate and identify any potential triggers prior to an incident. The in-service included to ensure that resident centered interventions are developed to alleviate/decrease behaviors and to communicate identified triggers and interventions to staff (Completion date of 9/27/21). 6.) Residents identified during IDT review for behavioral changes in #5 will be discussed during morning meeting and a root cause analysis will be completed to determine potential triggers. 7.) New interventions will be communicated to staff using a communication book. As of 10/4/21 at 2:10pm, V4 Registered Nurse (RN) was unaware of the communication book and did not know what staff or V4 was supposed to do with the book or what it was for. V1 (Administrator in Training) stated V1 is updating (direct care staff) when (V1) sees them related to the communication book.

Based on interview, record review and observation the facility failed to notify the physician of a worsening pressure sore, failed to monitor a pressure sore and skin integrity, failed to provide treatment; nutritional and pressure relieving interventions for pressure sores and failed to implement a physician's orders [REDACTED]. These failures resulted in R1 developing a stage three pressure sore to the coccyx and an unstageable pressure sore to the heel. Findings include: 1. The Admission History and Physical dated 12/2/15 documents R1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The Operative Report dated 12/4/15 documents R1 underwent a left below knee amputation on 12/3/15. The Discharge Packet dated 12/10/15 documents that R1 was discharged from the hospital with instructions to follow up with Z3 Urologist in two weeks to monitor penis wound. The physician's orders [REDACTED]. The Nursing Assessment documents one additional wound from R1's left below knee amputation. Nurses Notes dated 12/10/15 through 1/1/10/16 include no documentation related to pressure sores other that R1's penis wound. R1's Nurses Notes dated 12/10/15 through 1/10/16 document the following regarding R1's penis wound: 12/19/15 9:00 PM Resident remains on isolation [MEDICAL CONDITIONS] at penis TAO (triple antibiotic ointment) applied. 12/20/15 8:00 PM TAO ointment applied to necrotic area on penis. 12/24/15 4:00 PM Penis has open area approximately 2 cm (centimeters) uneven in shape that is raw area 0.25 cm black in center. 12/29/15 10:00 AM Black area on penis. R1's Treatment Administration Records (TAR) dated 12/1/15 through 12/31/15 documents no monitoring of R1's penis wound. R1's TAR dated 1/1/16 through 1/31/16 documents one entry regarding R1's penis wound dated 1/6/16 stating only necrotic area tip of penis. R1's TAR dated 12/1/15 through 12/31/15 documents Weekly Skin Checks and no dates are initialed to indicate a skin check was completed for R1. R1's TAR dated 1/1/16 through 1/31/16 documents instructions for staff to complete skin checks daily starting 12/10/16. The word daily is crossed out and replaced with weekly. A skin check is initialed as being completed on 1/6/16 and no other dates are initialed. R1's Skin Assessment for Predicting Pressure Ulcer Risk dated 12/31/15 documents that R1 is at high risk for pressure sore development. Nurses Notes dated 1/10/16 at 6:10 AM document (R1) transported to .hospital for surgery (colon resection). Z5's (Hospital Nurse) Nurses Notes dated 1/10/16 at 10:00 AM document the following pressure sores were present on R1's skin at the time of his admission to the hospital: Midline Coccyx Stage three Tip of penis Right Heel, Unstageable Z7's (Hospital Nurse) Nurses Notes dated 1/11/16 document (R1) Pressure Ulcer .stage indeterminable .Meatus .length 2cm, width 1 cm, and depth 0.3 cm and (R1) Right heel Pressure ulcer .unstageable eschar complete .length 4 cm, width 3cm. On 1/21/16 at 9:40 AM Z6 (Surgeon) stated that it is unlikely that R1 developed the stage three coccyx pressure sore and the unstageable right heel pressure sore while being transported to the hospital and that not completing daily skin checks could have contributed to the development or worsening of the wounds. Z6 went on to state that R1 had a large ulcer on the tip of his penis that appeared to have been caused by pressure from a urinary catheter that was anchored too tightly to R1's leg. R1's Medical Record does not include documentation that R1 followed up with Z3 after being discharged from the hospital (on 12/10/16). On 1/21/15 at 8:25 AM Z4 (Z3's Office Manager) stated that R1 has never had an appointment to see Z3 or any Urologist in the office. On 1/20/16 at 1:10 PM E2 Director of Nurses could not provide documentation that R1 followed up with Z3, that daily skin checks had been completed or that R1's penis wound was appropriately monitored after he was discharged from the hospital on [DATE]. At that time E2 stated that R1 should have followed up with Z3 and staff should have been completing daily skin checks for R1. The Decubitus Care/Pressure Areas policy dated 5/2007 states Documentation of the pressure area must occur .at least once each week on the TAR. The assessment must include .size, shape, depth, color . Pressure Sore Prevention Guidelines dated 4/2006 states The following guidelines will be implemented for any resident assessed at a .high risk for skin breakdown .daily skin checks. 2. The Weekly Wound Tracking sheet dated 1/13/16 documents that R3 acquired a stage two pressure sore on her coccyx on 1/12/16. Z1's (Hospice Nurse) Clinical Note dated 1/14/15 documents (R3) has a stage two pressure ulcer that measures 4.5 (centimeters (cm)) by 3 (cm) that is 100% slough on her sacrum .spoke with (Z2 Physician) .ordered a dressing change: cleanse wound with wound cleanser, pat dry. Apply calcium alginate to wound and cover with adhesive foam dressing. Change daily. The undated TAR documents that R3's coccyx wound dressing is scheduled to be completed by the 6:00 PM to 6:00 AM shift and that the treatment was completed by E5 Licensed Practical Nurse (LPN) on 1/15/16, 1/16/15 and 1/17/15. R3's pressure sore treatment is not initialed as being completed on 1/18/16 on the undated TAR. R3's Medical Record does not document that E4 Dietician was notified of R3's pressure sore or include a nutritional assessment related to R3's pressure sore. On 1/19/16 at 2:10 PM E5 LPN confirmed that she completed R3's daily pressure sore treatment on 1/15/16, 1/16/16 and 1/17/16. At that time E5 stated she noticed that tunneling was present at the base of R3's coccyx pressure sore on 1/17/16. E5 stated she did not notify the on coming nurse, Z2 Physician or Z1 Hospice Nurse about the development of tunneling in R3's pressure sore. On 1/19/16 at 2:00 PM E3 LPN stated she was R3's nurse on 1/18/16 (6:00 PM to 6:00 AM). E3 stated she did not see R3's coccyx pressure sore during her shift and she did not remember changing the dressing to R3's pressure sore. On 1/19/16 at 10:30 AM Z1 stated that a dressing was not in place over R3's coccyx pressure sore when she observed it this morning. Z1 stated that R3's pressure sore had worsened from a stage two pressure sore (on 1/14/16) to a stage three pressure sore with tunneling and that the wound bed had deepened to a depth of 1.5 cm to 2 cm. Z1 stated facility staff did not notify her that R3's pressure sore was worsening. On 1/20/16 at 10:40 AM E2 Director of Nurses stated she would have expected the nursing staff to notify the dietician of R3's newly developed pressure sore and that E5 should have notified E2, Z1, Z2 and the next shift nurse of R3's worsening pressure sore. The Decubitus Care/Pressure Areas policy dated 5/2007 states Nursing personnel are to notify dietary personal of any pressure areas to seek nutritional support . The Skin Care-Wound Care Teaching Protocols dated 4/2007 states notify the physician of any changes in skin integrity of lack of progress. 3. The Minimum (MDS) data set [DATE] documents R4 is severely cognitively impaired and requires total assistance with with eating. The Skin assessment dated [DATE] documents that R4 is at high risk for skin break down. The physician's orders [REDACTED].double protein at breakfast/lunch . On 1/19/16 at 12:40 E7 Activity Director fed R4 100% of a pureed lunch including a single serving pureed bread, fruit, chicken fried steak, greenbeans and mashed potatoes. On 1/19/16 at 12:50 PM E7 confirmed that R4 ate 100% of her lunch and stated that she received a single serving of each item. On 1/20/16 at 8:30 AM E8 Social Services Director fed R4 100% of a pureed breakfast including a single serving of pureed eggs. On 1/20/16 at 9:05 am E8 stated R4 ate all of her breakfast. E8 stated R4 did not receive an extra serving of eggs and stated she did not offer R4 a second serving of anything. On 1/20/16 at 9:15 AM E9 Dietary Manager reviewed R4's POS for double protein at breakfast and lunch and stated (R4) should have gotten an extra serving of eggs this morning. E9 stated the cook must have made a mistake. 4. The MDS dated [DATE] documents that R2 is severely cognitively impaired. The Weekly Wound Tracking sheet dated 1/18/16 documents that R2 has a right hip stage two pressure sore. The POS dated 1/8/16 documents orders for R2 to wear bilateral heel protectors and whole milk to replace menu milk. E6's RD (Registered Dietician) Note states PU (pressure ulcer) referral .recommend whole milk with each meal rather than bid (twice daily) . On 1/19/16 at 12:45 PM E10 Certified Nurses Aide fed R2 lunch. R2 had a glass of juice, a glass of water and a cup of coffee in front of him at the table. R2 did not have a glass of milk. On 1/19/16 at 1:10 PM E10 stated R2 had water, juice and coffee to drink at lunch. On 1/20/16 at 9:10 AM E9 stated that R2 only receives milk twice daily at breakfast and dinner. On 1/19/16 at 12:45 PM and 1:20 PM R2 was seated in a high back wheel chair with his feet resting on the floor and no heel protectors on his feet. On 1/19/16 at 11:40 AM R2 was in bed with no heel protectors on his feet. On 1/20/16 at 8:40 AM, 9:20 AM and 11:15 AM R2 was seated in a high back wheel chair with his feet resting on the floor and no heel protectors on his feet. On 1/20/16 at 1:00 PM R2 was lying in bed with no heel protectors on his feet. On 1/20/16 E11 Certified Nurses Aid confirmed that R2 was not wearing heel protectors. At that time E11 stated that R2 had heel protectors when he returned from the hospital (1/8/16) and she does not know why R2 has not been wearing them.

Based on observation, record review and interview, the facility failed to provide safe supervision and utilization of devices for one of four residents reviewed for falls (R7) and one of five residents reviewed for side rails (R4) in the sample of ten, by failing to secure the mechanical lift (R7), and failure to utilize a safe side rail and pad the side rail as directed (R4). This failure for R7 resulted in a fall out of the mechanical lift, requiring hospital treatment and sutures. Findings include: 1. According to the current physician's orders [REDACTED]. The Minimum (MDS) data set [DATE] assesses R7 with severe cognitive impairment and totally dependent on staff for all activities of daily living. R7 was assessed on 3/10/12 as a high fall risk. The careplan last reviewed on 8/9/12 states that R7 is transferred by mechanical lift with 2 staff persons. Nurses notes written by E3 (nurse) for 4/27/12 at 6:15pm state the following: ". . .Found res. on floor under {mechanical} lift, Rt (right) flank over leg of {lift}; head face down on floor {with} blood coming from laceration of mid-center forehead. 2.5cm (centimeter) {by} 1.0cm laceration. . . ." The physician was called and R7 was sent to the hospital. Hospital emergency records dated 4/27/12 show that R7 had a 3cm laceration that required 3 subcuticular sutures and 8 skin sutures. R7 returned to the facility the same evening. The Fall Documentation sheet and the Investigation Report for falls dated 4/27/12 state that while being transferred per mechanical lift by E13 and E14 (Certified Nurse Aides/ CNAs), the "strap on hook came loose" and R7 fell to the floor. The interventions to prevent falls is "All CNAs are to read manual regarding lift." The written statement by E13 dated 4/27/12 states that "the top hooks was hooked on blue on the pad and the bottom was hooked on purple as we was moving him to the bed. The left bottom hook came undone and he fell forward and to the left. "E14's written statement dated 4/27/12 stated that the sling "was placed on the first loop on the top and the third on the bottom as we were taking him up the left bottom {sling loop} snapped off. . . ." E3's written statement dated 4/27/12 states that when E3 arrived in the room "Res was found on Rt side.. . . . 3 hooks on {lift} were secure. Rt top hook was off. . . ." On 8/14/12 at 12:20pm, E3 stated that it appeared that the loops on the lift sling were not secured correctly. E3 demonstrated on the sling that the correct color loops for top and bottom are to be secured, and then the top black "rescue loop" is also secured, so that if the colored loop slips, there is the top loop to stop a fall. On 8/15/12 at 2:00pm, E14 stated that on the day of the fall, E13 had asked for help in transferring R7 after supper from the wheelchair to bed. E14 stated that when E14 arrived in the room, E13 had already placed the sling loops on the mechanical lift. E14 stated that she noticed one of the loops was not secured correctly and she fixed it. E14 stated that she did not check all the loops to see that they were double-looped, and "she wished she had." E14 stated that as they were lifting R7 up from the chair the left loop came loose and R7 fell on to the floor. E14 stated that the sling loops are always to be double-looped. On 8/15/12 at 2:15pm, E2 (Director of Nursing) stated that the cause of the fall was that staff did not correctly secure the sling to the mechanical lift. 2. R4's Physician order [REDACTED]. R4's Minimum Data Set ((MDS) dated [DATE] identifies R4 with severe cognitive impairment, requires extensive assistance of staff for transfers, is non ambulatory and utilizes bedrails. R4 is assessed with [REDACTED]. On 8/13/12 at 11:20am R4 was seated in a high back wheelchair with footrests, right wheelchair arm bolster, and a pelvic restraint. Per interview with Director of Nurses E2 on 8/14/12 at 12:55 pm R4 is "like a noodle" and utilizes the restraints and bolsters for positioning and to prevent scooting down in the wheelchair. R4's Fall Risk assessment dated [DATE] showed R4 is high risk for falls. R4's Nurse's notes dated 6/11/12 document "not sleeping past three nights, restless....she tries climbing out of bed, hanging legs over side of bed, staying in a lying position." Notes dated 6/24/12, 6/25/12, 7/13/12, documents R4 restless in bed at night often, desires to get up at 2 am. Nurse's notes dated 12/18/11 documented R4 attempted to climb out of bed and caught hand on siderail and received two skin tears. R4 also had a fall out of bed per 11/20/11 nurse's notes with the 1/2 rails in place and received an skin tear and abrasion. R4 was diagnosed with [REDACTED]. The facility investigation of the injury of unknown origin dated 1/9/12 documented a physician assessment of a "billy club fracture caused by hitting a hard object that could have been caused by the bedrail." On 8/13/12 at 1:15 pm Certified Nurse Aide E15 and E7 were coming out of R4's bedroom. E15 stated they had just laid R4 down. R4 was in bed on her back with the head of the bed slightly elevated. Bilateral 1/2 bedrails were in the upright position on the bed. The rail against the wall was fully padded, however the bedrail on the outside was not padded. There were wide spaces between the bars of the bedrails from 5-7 inches wide that could allow R4 to place an arm, leg or head through. The center opening was 7 inches wide and 15 inches high. R4's head was next to this opening. On 8/13/12 at 1:45 pm, R4 was in bed, leaning toward the unpadded rail and at 2:00 pm was in the same position. On 8/13/12 at 4:20 pm R4 was awake in bed lying on her back. R4 had her knees bent and used her feet to push herself up. The outside rail was not padded. R4's care plan dated 5/21/12 states R4 uses a side rail as an enabler that does not limit movement or accessibility. The 1/2 bilateral side rails are to be padded for safety as R4 has [DIAGNOSES REDACTED]. The care plan lists R4 at risk for bruising and skin tears and documented R4 was able to turn and reposition self in bed at night. It did not address R4's history of restlessness, attempts to get out of bed, or past history of injuries from bedrails. On 8/14/12 at 1:15 pm R4 was asleep in bed with the outside rail in the upright position and unpadded. R4 was again in bed on 8/14/12 at 3:30 pm,and 3:55 pm. On 8/14/12 at 3:55pm Director of Nurse's E2 was shown R4's bedrail and informed of the potential for entrapment and also the lack of padding. E2 stated that R4 should not have that type of bedrail. E2 stated R4 had been moved to the current room on Friday (8/10/12) and staff did not bring the bed with the correct padded rails to the new room.

A. Based on interview and record review facility staff failed to assist or supervise R4 while she was attempting to put on her pants. As a result R4 fell and hit her face. R4 sustained a laceration and a contusion that required a visit to the emergency room and four stitches. R4 is 1 of 4 residents reviewed for falls on the sample of 11. Findings include The September 2011 physician's orders [REDACTED]. The Care Plan dated 5/2/2011 documents R4 had falls on 3/31/2011, 4/18/2011, 4/27/2011, and 6/30/2011. The 3/29/2011 and the 6/28/2011 Minimum Data Sets both document R4 needs assistance with dressing. The (MDS assessment tool) Resident Characteristic Report for 6/21/2011 through 6/27/2011 (the seven days before R4 fell ) indicates she needed supervision with dressing that entire week. R4 had a fall with injury on 6/30/2011 while trying to dress herself. The Incident Investigation Form dated 6/30/2011 states: "...CNA (Certified Nursing Assistant) took (R4) her clothes so (R4) could get up this AM. CNA left room to see to other residents, a few minutes later, resident was yelling out for help & CNA ran down to her room. (R4) was on the floor (with) a small laceration to her eyebrow area & swelling noted. Nurse notified...Assisted up by staff. MD (Medical Doctor) notified & Pt. sent to ER (emergency room ) for possible sutures. Pt. returned to facility (with) 4 sutures to (left) eyebrow area..." The Incident Report Form dated 6/30/2011 states "...CNA took res her clothes from closet...shortly afterward CNA heard bed alarm & resident yelling 'help.' When checked by CNA , res was on her floor. CNA noted bleeding & swelling to (left) eye/cheek area...Nurse asked resident what happened. Res replied - 'I got my foot caught.' E2 Director of Nurses stated on 9/9/2011 at 10:00 AM, "...(R4) had her slacks half way up and decided she had to go to the bathroom. She forgot she had her pants half way up. She tripped herself when she tried to walk. The CNA should not have left her alone to put on her own pants. That is why she fell ..." E5 Occupational Therapy Assistant stated on 9/9/11 at 10:00 AM, "...(R4) has no safety awareness. You cannot leave her alone without supervision. She will not follow direction..." B. Based on observation, interview, and record review the facility failed to ensure that electrical extension cords were not used to power an electromechanical medical device used by R29, 1 of 6 supplemental residents in the facility with such devices. The facility failed to ensure that extension cords were not used to power high amperage devices such as window air conditioning units in 23 of 27 resident bedrooms. These failures represent a potential fire safety risk potentially affecting 9 of 11 sampled residents (R1, R2, R3, R4, R6, R7, R8, R9, and R10) residing in 8 bedrooms and occupants of the remaining 15 bedrooms. Findings include the following: 1. On 9-6-11 at 11:15 a.m. an electromechanical low air flow mattress used by R29 was plugged into an extension cord in R29's bedroom. The window air conditioner unit in this room was also plugged into an extension cord. This extension cord was plugged into an (extension cord) electrical power strip which was connected to the wall outlet. E2, Director of Nursing stated on 9-13-11 at 11:45 a.m. that there are no other electromechanical medical devices in the facility being powered by extension cords. E2 stated that 6 residents use electromechanical medical devices. 2. E18, Maintenance Supervisor stated on 9-13-11 at 10 a.m. that 26 of 27 resident bedrooms in the facility are equipped with window air conditioning units. E18 stated that 23 of the 26 air conditioning units are powered with extension cords plugged into wall outlets. Some air conditioning units were also powered by the use of electrical power strips connected to wall outlets. E18 stated that there are limited electrical outlets available in resident bedrooms which require the use of extension cords. E18 stated that he was unaware of any rules prohibiting use of extension cords for these devices. E18 stated that while some residents do not use the air conditioners, others use them daily through the cooling season. E1, Administrator stated on 9-13-11 at 1 p.m. that it is not financially feasible to install wall outlets in resident bedrooms. E1 indicated that the extension cords were being used on a 'temporary' basis. Air Conditioner Manufacturer documentation (User's Manual) for one style of air conditioner being used states " ...Temporary Use of an Extension Cord ...We strongly discourage (bold emphasis) the use an extension cord due to potential safety hazards ... " C. Based on observation, interview, and record review the facility failed to maintain hot water temperatures at a safe level at the hairwashing sink in the beauty shop. This has the potential to cause burns and could affect any residents using the beauty shop services. Findings include the following: On 9-13-11 at 9:30 a.m. hot water at the hairwashing sink in the beauty shop measured 127 degrees Fahrenheit (F.) above the maximum permitted 110 degrees F. Water felt extremely hot at this location. Steam vapor was present when hot water was permitted to flow from the hand held sprayer. E18, Maintenance Supervisor stated at this time that he was unsure of the heating source of this water and did not know if the heating source had any thermal regulating device such as a thermostatically controlled mixing valve. E18 stated that he checks the hot water at this location once weekly and last checked it about a week earlier. E1, Administrator provided documentation of hot water weekly checks. Log documentation yielded no information regarding hot water monitoring at this location. E1 stated that the door to this room is locked at all times. E1 and E18 stated that resident use of beauty shop services varies from week to week. E1 and E18 stated that there have been no injuries reported from contact with excessively hot water. The Centers for Medicare and Medicaid Services 672 form completed on 9-6-11 reflects there are 41 residents in the facility.