Every finding on record at Eastside Health and Rehabilitation Center

Based on interview, observation, and record review, the Facility failed to ensure food was stored in a manner that prevents foodborne illness. This has the potential to affect all 55 residents living in the Facility. Findings include: On 6/4/25 at 9:15 AM, in the standing freezer there was a plastic bag with uncooked steak that was not labeled or dated. The bag was previously opened and was not resealed, leaving the meat open to air. There was a bag of uncooked chicken that was not labeled or dated. The steak and chicken were both stored on the top shelf next to a sponge cake and directly above a box of dinner rolls. V4, Dietary Manager, stated, We can probably get rid of those. They have been in there for a while. On 6/4/25 at 9:20 AM, in the resident refrigerator there was a carton of ham salad with R50's name on the label. The sell by date was 5/28/25. There was a plastic bag of deli meat that was not dated. The bag had been opened and was not resealed, leaving contents open to air. V4 stated that should have a label on it. On 6/4/25 at 9:23 AM, in the standing refrigerator there were two pitchers labeled sweet tea with use by dates of 5/9. There were two pitchers labeled lemonade with use by dates of 5/9. There was a pitcher containing a clear liquid with no label or date. There were 26 individual cups of assorted colored liquids on a tray that were not labeled or dated. There was a plastic container labeled turkey with use by date of 5/9. V4 stated, We will throw that out. On 6/6/25 at 9:48 AM, V1, Administrator, stated she expects staff to follow the Facility's food storage guidelines. The Facility's Undated Food Storage Policy documents, Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. Store raw animal foods such as eggs, meat, poultry, and fish separately from cooked and ready-to-eat food. If they cannot be stored separately, place raw meat, poultry and fish items on shelves beneath cooked and ready-to-eat items. It multiple shelves are available, the raw animal food with the highest final cooking temperature shall be stored on the lowest level, i.e. poultry and stuffed foods. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 6/4/25 documents there are 55 residents living in the Facility.

Based on observation, interview and record review the facility failed to prevent abuse for 1 (R160) of 4 residents in a sample of 23. 1. R37's Undated Face Sheet, documents he was initially admitted to the facility on [DATE] and diagnoses included COPD (Chronic Obstructive Pulmonary Disorder), gastric ulcer, malignant neoplasm of ascending colon, heart attack, chronic viral hepatitis, GERD (Gastroesophageal Reflux Disorder), malaise and diabetes. R37's Annual Minimum Data Set (MDS) dated [DATE] documents he was alert and had no physical behaviors and had verbal behavioral symptoms directed towards others 4-6 days. R37's Care Plan, dated 11/15/2024 documents focus: behavior can be easily annoyed/agitated, and impatient. He becomes rude and hateful and has verbal aggression at times. He at times will yell/cuss at staff. He will usually stop when asked to. Often apologizes later for behavior. Goal: Behavior(s) will not interfere with other residents' rights through next review. R37's Nurse Progress Note, dated 12/4/2024 no documentation of a resident-to-resident altercation. 2. R160's Face Sheet, documents she was initially admitted to the facility on [DATE] and diagnoses included dementia. R160's Quarterly MDS, dated [DATE] documents she was alert and had no physical and verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) occurred 1 to 3 days. R160's Undated Care Plan, didn't address that she was at risk for abuse. R160's Nurse Progress Note, dated 12/4/2024 no documentation of a resident-to-resident altercation. R160's Nurse Progress Note, dated 3/1/2025 at 3:30 PM documents she was discharged from the facility at that time. IDPH (Illinois Department of Public Health) Notification Form, dated 12/4/2024 documents R37 and R160 had an incident on 12/4/2024 at 12:05 PM. Description: On 12/4/2024 at approximately 12:05 PM staff reported an alleged resident to resident physical altercation. Residents immediately separated. Both residents assessed with no injury noted. Both residents PCP (personal care physician), POA (power of attorney)/resident representative. Ombudsman and local PD (police department) notified. Investigation initiated. Will send a follow up report within 5 working days. A Written statement dated 12/4/2024 at 12:05 PM V19, CNA (Certified Nurses Assistant) documented, I was sitting at the assist table and seen (R160) propelling her w/c (wheelchair) out of the dining room when she accidentally bumped (R37's) wheelchair and (R37) became upset and hit her. I immediately got up and helped (R160) out of the dining room then (R37) was fine. V1 documented this written statement. A Written Statement dated 12/4/2024 at 12:15 PM staff asked R160 what happened, and she stated, I'm not sure. I was trying to get out of the dining room. I had my head down I didn't see him until I seen his hand. Staff asked did he say anything to you? R160 responded, Not that I heard. Staff asked did you say anything to him? R160 responded, No, I didn't. V1 documented this written statement. On 6/4/2025 at 10:00 AM R37 lay in bed. R37 didn't respond to any questions asked by the IDPH surveyor. On 6/5/2025 at 11:30 AM R37 lay in bed. No response from resident regarding hitting (R160) on 12/4/2024, he just stared at me. On 6/6/2025 at 10:45 AM, V1 Administrator stated she recalled the altercation between (R37) and (R160.) V1 stated the altercation was witnessed by a CNA who reported (R37) hit (R160) across on the cheek in December 2024. V1 stated staff separated the residents immediately and there was no red mark on (R160's) cheek. V1 stated (R37) doesn't have a history of hitting other residents before this incident and hasn't hit any resident since the incident. V1 stated (R160) didn't have behaviors while she resided at the facility. The Facility's Typed Letter dated 12/11/2024 documents this letter will serve as a follow up to the initial notification sent on 12/4/2024 regarding an allegation of a resident-to-resident physical altercation between (R37) and (R160). On 12/4/2024 at approximately 12:15 PM V19, CNA reported an allegation of resident-to-resident physical altercation between (R37) and (R160.) Both residents were immediately separated and assessed with no injury noted. The facility-initiated investigation per protocol including notification of both resident's physician's and families, the ombudsman and the local police department. (R37) was interviewed and voiced (R160) bumped into his wheelchair as she was leaving the dining room. (R37) alleges a verbal exchange between them but was unable to voice what was said. (R160) was interviewed and voices she is unsure what happened. (R160) voices that she had her head down and the next thing she saw was (R37's) hand. (R160) voices she did not speak to (R37.) Staff interviews reveal that (R160) did bump into (R37's) wheelchair while attempting to leave the dining room. No one voiced witnessing any conversation between (R160) and (R37.) V19, CNA was interviewed and stated she was at the table assisting a resident and witnessed (R160) bumping into (R37's) wheelchair but she did not hear any conversation between the two residents. She immediately got up and assisted (R160) out of the dining room. This typed follow-up letter did not document that staff (V19, CNA) observed (R37) hit (R160) in the dining room during the resident-to-resident altercation. The Facility's Abuse Prevention Policy revised 11/28/2016, documents this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as denied below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment, The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents.

Based on observation, interview and record review the facility failed to ensure progressive interventions are documented on resident's care plan for 1 of 5 (R12) residents in a sample of 23. Findings include: R12's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] and diagnoses included dementia, chronic pain, GERD (Gastroesopageal Reflux Disorder), hypertension, depression, IBS (Irritable Bowel Syndrome), insomnia, anxiety, malnutrition and osteoarthritis. R12's Quality Care Reporting Form, dated 2/4/2025 documents R12 sustained a left lower extremity skin tear during a transfer by bumping it on wheelchair pedal. Leg sleeves for the intervention documented. R12's Quality Care Reporting Form, dated 2/5/2025 documents R12 sustained a right forearm skin tear from bumping arm on wheelchair arm rest. Arm sleeves for the intervention documented. R12's Bruise/Skin Discoloration Incident Report, dated 3/19/2025 documents nursing description: during ADL care noted to have 6.5 CM (Centimeter) x 5.5 CM dark purple bruise to right lower arm poor nutrition, hospice care, fragile, restless with transfers causing arm to hit w/c (Wheelchair) requiring area. Resident description: Unable to answer. Incident witnessed: No. Questioned what happened and if it hurt, denies pain, MD (Medical Doctor) notified. DON (Director of Nursing) notified. POA (Power of Attorney) notified. Injuries observed at time of incident: bruise on right forearm. Other info: needs frequent reminders to wait for assistance for transfers. No intervention documented on the incident report form. On 6/5/2025 at 11:30 AM V16, LPN (Licensed Practical Nurse) stated she was familiar with (R12) and recalled in March 2025 she was very confused and had a UTI (Urinary Tract Infection) so that increased her confusion. V16 stated (R12) consistently hit her arms against her wheelchair arms and that is how the bruise was sustained. V16, LPN stated she transferred (R12) from her wheelchair to her recliner that day she noted the bruise on (R12's) right forearm and documented it. V16 stated the bruise didn't occur during the transfer as it was already there and that it most likely occurred because (R12) was so restless and hit her arms on the wheelchair arms during that time. V16 stated she notified V2 of the bruise but she didn't recall what intervention was put in place at that time. R12's Undated Care Plan documents skin integrity resident is at risk for skin breakdown d/t (due to) frail skin and can be resistive with peri care at times. Interventions: 6/4/2025 leg sleeves on AM off HS (bedtime) to wear at all time d/t frail skin with risks for s/t's (skin tears.) 2/6/2025: Observe skin with AM/PM care and with toileting for redness, rashes, open areas, pain, swelling and report them to team leader. Weekly skin check. No intervention of arm sleeves documented for skin tear that was sustained on 2/5/2025. Leg sleeves were not documented on R12's care plan until 6/4/2025 for skin tear sustained on 2/4/2025 and no intervention documented to prevent futher bruising to R12's arms. On 6/5/2025 at 2:00 PM V20, Care Plan Coordinator stated she works Monday through Friday and when she is at the facility and a new intervention is added for a resident she documents it on the care plan either the same day or the next day and on the weekends the nurse starts the intervention immediately and she is notified of the new intervention and she documents the new intervention on the resident's care plan on Monday. During an interview on 6/6/2025 at 9:20 AM V2, DON stated according to the incident report dated 3/19/2025 its documented the bruise (R12) sustained on her right forearm occurred during a transfer but V16 documented the incident wasn't witnessed so she was confused by this documentation. V2 stated if (R12) was restless and hitting her arms against her wheelchair arms an appropriate intervention would be to pad the wheelchair arms to prevent further bruising/injuries. V2 stated nurses have access to resident's care plans and she expected the assigned nurse to add an intervention to the resident's care plan the same shift the incident occurred. The Facility's Care Planning Policy dated 12/2024, documents every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines in the Resident Assessment Instrument (RAI) manual. The comprehensive plan of care must address all care issues that are relevant to the individual. No documentation on the care planning policy to show what timeframe to add/document progressive interventions on resident's care plan.

Based on interview and record review, the facility failed to provide adequate supervision to prevent falls and implement progressive interventions for accidents and falls for 3 of 4 residents (R35, R12, R46) reviewed for accidents and hazards in the sample of 23. Findings include: 1. R35's Face Sheet documents R35 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, chronic obstructive pulmonary disease, and mild dementia. R35's Minimum Data Set (MDS) dated [DATE] documented R35 was moderately cognitively impaired and required supervision with showering. R35's Care Plan revised 3/11/25 documents R35 has risk factors requiring monitoring to reduce the potential for self-injury. R35's Fall Risk assessment dated [DATE] documented R35 was at risk for falls. R35's 3/22/25 Fall Investigation by V17, Licensed Practical Nurse (LPN), documents V17 entered the bathroom and found R35 sitting on her buttocks in front of the shower stall. R35 stated she was adjusting towel on the seat of the shower chair before sitting down and lost her balance, landing on her buttocks. Injuries included bruises to sacrum, right forearm, and left forearm. R35's Skin Inspection assessment dated [DATE] documents R35 had bruises to sacrum, left forearm and right forearm related to fall. On 6/5/25 at 2:45 PM, R35 stated she was alone when she fell in the shower room. She remembers an aide stepping out of the room prior to her fall, but she cannot remember which aide it was. R35 got up to get shampoo, then was putting a towel on the shower seat when her legs gave out and she landed on her bottom. She stated she still has trouble with that hip, because it hurts when she gets out of bed in the morning, and it still just is not right. On 6/5/25 at 2:35 PM, V17 was not available for interview by phone. On 6/5/25 at 1:38 PM, V1, Administrator, stated staff were not with R35 when she fell and would expect staff to stay with residents who require supervision with showering. 2. R12's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] diagnoses included dementia, anxiety, depression and hypertension. R12's Undated Care Plan, documents no documentation of bruises or interventions to prevent resident from bruising. R12's Nurse Progress Note, dated 3/19/2025 at 7:23 PM documents a 6.5 CM (centimeter) x 5.5 CM dark purple bruise noted to right lower forearm. Resident states IDK (I don't know) when asked what happened. Denies pain. DON (Director of Nurses), POA (power of attorney) and MD (physician) updated. Will monitor until healed. R12's Bruise/Skin Discoloration Incident Report, dated 3/19/2025 documents nursing description: during ADL (Activities of Daily Living) care noted to have 6.5 CM x 5.5 CM dark purple bruise to right lower arm poor nutrition, hospice care, fragile, restless with transfers causing arm to hit w/c (Wheelchair)requiring area. Resident description: Unable to answer. Incident witnessed: No. Questioned what happened and if it hurt, denies pain, MD notified. DON notified. POA notified. Injuries observed at time of incident: bruise on right forearm. Other info: needs frequent reminders to wait for assistance for transfers. R12's Significant Change Minimum Data Set (MDS) dated [DATE] documents no physical or verbal behaviors and no rejection of care. On 6/5/2025 at 11:30 AM V16, LPN stated she was familiar with (R12) and recalled in March 2025 she was very confused and had a UTI (Urinary Tract Infection) so that increased her confusion. V16 stated (R12) consistently hit her arms against her wheelchair arms and that is how the bruise was sustained. V16 stated she transferred (R12) from her wheelchair to her recliner that day she noted the bruise on (R12's) right forearm and documented it. V16 stated the bruise didn't occur during the transfer as it was already there and that it most likely occurred because (R12) was so restless and hit her arms on the wheelchair arms during that time. V16 stated she notified V2 of the bruise but she didn't recall what intervention was put in place at that time. On 6/5/2025 at 11:45 AM V11, CNA (Certified Nurse Assistant) stated (R12) is confused and she gets upset at times and hits her arms against her wheelchair arms. V11 reviewed the daily staffing dated 3/19/2025 and stated according to the staffing document she was assigned to (R12) on 3/19/2025 but she didn't recall (R12) hitting her arms on her wheelchair or observing a bruise on (R12's) arm that day. On 6/5/2025 at 10: 20 AM V14, CNA stated she is assigned to (R12) today and stated (R12) is confused and gets physical at times, hitting her arms against her wheelchair arms when she gets mad. On 6/5/2025 at 12:10 PM V15, CNA stated (R12) is confused and does hit her arms on her wheelchair at times when she is upset. On 6/5/2025 at 12:10 PM R12 lay in bed with her eyes open. IDPH surveyor asked her if she knew how she got the bruise on her arm on 3/19/2025, (R12) laughed and shrugged her shoulders and said, I don't remember. On 6/5/2025 at 1:40 PM, V2 Director of Nurses (DON) and V3 Assistant Director of Nurses (ADON) assessed (R12's) arms. V2 removed R12's geri sleeve on her left arm. V3 stated there was a dark pinkish/purple bruise mid forearm that measured 2.0 cm x 1.5 cm, V3 asked (R12) how she got that bruise and (R12) stated probably from the fall. V2 removed (R12's) geri sleeve on her right arm. V2 stated there was a purplish/pink bruise mid forearm that measured 1.4 cm x 1.9 cm. V2 asked (R12) how she got that bruise and (R12) stated probably from the fall. V3 stated (R12) had fell but that was a while ago. V2 stated (R12) probably got the bruises from bumping them against her wheelchair. During an interview on 6/6/2025 at 9:20 AM V2, DON stated according to the incident report dated 3/19/2025 its documented the bruise (R12) sustained on her right forearm occurred during a transfer but V16 documented the incident wasn't witnessed so she was confused by this documentation. V2 stated if (R12) was restless and hitting her arms against her wheelchair arms an appropriate intervention would be to pad the wheelchair arms to prevent further bruising/injuries. On 6/6/2025 at 10:10 AM V1, Administrator stated she isn't sure the facility has an accident/incident policy, and she will look. On 6/6/2025 at 1:00 PM no facility accident/incident policy received. 3. R46's Undated Face Sheet documents R46 was admitted to the facility on [DATE] and has a diagnosis of Dementia, Major Depressive Disorder, Adjustment Disorder with Depressed Mood, Anxiety Disorder, Type 2 Diabetes Mellitus, Hypertension, Lack of Coordination, and Muscle Wasting and Atrophy. R46's Care Plan with an initiation date of 6/14/2024, documents R46 has risk factors that require monitoring and intervention to reduce potential for self-injury. R46 has weakness, unsteady gait, takes psych meds, history of falls, confusion & gets up without assist. R46's Care Plan does not document new progressive interventions for R46's falls that occurred on 3/8/2025, 3/21/2025, 4/7/2025, and 5/1/2025. R46's Minimum Data Set (MDS) dated [DATE] documents R46 is mildly cognitively impaired and is dependent on the assistance of staff with toileting hygiene, getting from a sitting to a standing position, lying to sitting on the side of the bed, transferring from a chair to bed/bed to chair, and toilet transfers. The Facility's Monthly Fall Analysis Report documents R46 experienced a fall on 11/28/2024, 2/20/2025, 3/8/2025, 3/21/2025, 4/7/2025, and 5/1/2025. R46's Quality Care Reporting Form dated 11/18/2024 documents R46 sustained a fall with no injuries. R46 was getting up without assistance to go to the bathroom, no call light in use. Sign placed on bathroom door to remind resident to use call light and wait for assistance. Interventions implemented to prevent another fall includes sign on bathroom door- Call don't fall. Progress Note dated 2/20/2025 at 1:45 AM documents resident pressure alarm sounding. Resident sitting on the floor in front of her recliner, the footrest to the recliner still up. Resident says that she was trying to get up and the chair tipped forward and she slid to the floor. No injuries noted. Range of motion (ROM) within normal limits (wnl). Neuro checks started and wnl. Resident denies pain or discomfort. Resident assisted up per mechanical lift. Resident placed on 30 min checks for 24 hours. Progress Note dated 3/9/2025 at 5:15 AM documents residents pressure alarm sounding. Resident sitting on floor in front of toilet in resident bathroom. Resident had adult diaper down and floor was wet with urine. Resident also had bare feet, no shoes or slipper socks on. Resident just says that she slipped. Resident denies hitting head, but Neuro checks started due to (d/t) fall not witnessed. Neuros wnl. ROM wnl. Resident denies pain or discomfort. Resident got up from floor per mechanical lift. Attempted to notify Power of Attorney (POA), but no answer. Resident placed on 30 min checks for 24 hours. Progress Note dated 3/24/2025 at 10:34 AM documents Interdisciplinary Team (IDT) met to review fall from 3/21/25. Resident was in bathroom by self and was self-transferring from toilet, attempting to pull pants up by self and lost balance causing resident to fall onto buttocks in front of toilet. Fall intervention: Staff education to not leave resident on toilet by self. Progress Note dated 4/7/2025 at 3:29 AM documents residents alarm was sounding. Resident observed laying on the floor on her right side. Resident had got up without assist and without her walker and lost her balance and fell. No injuries noted. Resident denies hitting her head, but neuro checks started d/t unwitnessed fall. Neuro checks wnl. ROM wnl. Resident denies pain or discomfort. Resident got up off the floor per mechanical lift. Resident bought to recliner at nurses' station to be in view of staff. Resident placed on 30 min checks for 24 hours. Medical Doctor (MD) made aware. Attempted to call POA, but no answer. Progress Note dated 5/1/2025 at 9:55 AM documents Resident was sliding out of recliner at nurses' station and was lowered to the floor by staff. Resident was attempting to self-transfer. Pressure alarm was in place and functioning properly. MD and POA aware. No injuries voiced. Resident denies pain or discomfort. On 6/6/2025 at 9:49 AM V2, Director of Nursing (DON), stated a new intervention should be implemented on a resident's Care Plan after each fall. V2 stated new interventions can get tricky to come up with depending on the resident and how many falls they have experienced, but the goal is for a new intervention to be put in place with each fall. The Facility's Fall Prevention Policy revised 11/10/2018, documents policy to provide for resident safety and to minimize injuries related to fall; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Procedure: a fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place any new intervention on the CNA assignment worksheet. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.

Based on record review and interview the facility failed to provide a Registered Nurse (RN) 8 hours a day seven days a week. This has the potential to affect all 50 residents residing at the facility. Findings include: On 04/29/24 at 1:20 PM, the facility daily staffing sheets were reviewed. The staffing sheets documents there was no RN coverage for 8 hours a day in the facility for the following dates: 4/6/24, 4/7/24, 4/20/24 and 4/21/24. On 4/29/2024 at 3:09 PM, V1, Administrator, stated the facility does not have a policy on staffing. V1 stated a RN should be on duty 8 hours a day seven days a week. The CMS 671 Facility Application for Medicare and Medicaid, dated 4/29/2024, documents a census of 50 residents.

Based on observation, interview and record review, the facility failed to do complete hand hygiene, assist residents with handwashing, maintain a clean field during a wound dressing change, and ensure resident rooms and common resident-use areas are cleaned in a manner that prevents the spread of infection for 9 of 24 residents (R6, R7, R9, R11, R17, R18, R23, R33, R48) reviewed for infection control in the sample of 39. Findings include: R6's Laboratory Result, dated 4/9/24, documents R6 wound to R6's right leg is positive for Methicillin Resistant Staph Aureus (MRSA). On 4/30/24 at 9:13 AM, V13, Housekeeper, was seen cleaning R6's room. R6 was on contact isolation for MRSA. V13 stated that she uses this same cart to clean all rooms. V13 pulled a washcloth out of a bucket of water on the cart and took it into R6's room, began wiping things down, then placed the washcloth into a plastic bag. V13 used the toilet brush off her cart and cleaned R6's toilet and replaced it back on the cart. V13 used the broom off the cart, swept the floor, then put the broom back on the cart. V13 then used the mop sitting in the mop bucket and mopped R6's floor, then placed the mop back into the mop bucket of water. V13 finished R6's room and took the cleaning cart down the hall and began cleaning the West-Hall restroom/shower room with the same contaminated broom, mop, and mop water that was used in R6's isolation (MRSA) room. On 5/2/24 at 9:03 AM, V13, Housekeeper, stated that she changes her mop water whenever it looks dirty. V13 stated that on isolation rooms, she tries to change the water after every room, but sometimes she gets confused and forgets. V13 stated that the other day when she was cleaning (R6's) room, she did go into the shower room on the west-hall to clean that room after cleaning R6's. On 5/2/24 at 9:08 AM, V21, Housekeeper, stated that she starts out her shift with a clean mop bucket of water, she will clean and mop the non-isolation rooms first, then change the mop water, and then do the isolation rooms. When she is done with the isolation rooms, she will change the mop water and mop head. V1, Administrator, provided a list of residents who received a shower in the West-Hall shower room on 4/30/24. This was after V13 used contaminated mop water to clean the shower room. There were six residents R9, R11, R18, R23, R33, and R48 who received a shower in that shower room that day. On 5/2/24 at 9:28 AM, V20, Regional Nurse, stated the Routine and Terminal Cleaning of Isolation Rooms Policy, does not address mopping the floor, or when to change the mop water or mop head. V20 stated that she would expect the housekeeper to clean the broom and change the mop water and mop head after cleaning an isolation room. The Facility's Routine and Terminal Cleaning of Isolation Rooms, dated 5/30/14, documents To ensure all resident isolation rooms are clean and to prevent the spread of microorganisms. 2. On 5/1/24 at 9:42 AM, V16, Licensed Practical Nurse (LPN) was performing wound care on R6. V16 donned PPE (personal protective equipment) and removed the old dressing from R6's right leg. V16 donned new gloves with no Hand Hygiene done in between glove changes. V16 went into the restroom and got a paper towel from the wall dispenser, wet it from the restroom sink, then walked back to R6 and began wiping his wound on his right leg with the wet paper towel. V16 then used a dry paper towel from the restroom dispenser and dried off the wound. V16 doffed PPE and walked out of room and gathered supplies from the wound cart. V16 took out the Calcium Alginate from the original package and placed it on the top of the cart, without wiping the cart down or having a clean barrier. V16 then picked up the dry dressing, dated it, obtained Kling wrap, and tape, and again placed all supplies on top of the cart while donning PPE again. V16 then entered the room with supplies, and applied the Calcium Alginate to the wound, wrapped R6's leg with Kling, and secured with tape. R6's Laboratory Result, dated 4/9/24, documents R6 wound to his right leg has MRSA. R6's Wound Center Physician Order, dated 4/30/24, documents Cleanse the wound with mild soap and water, gently pat dry prior to applying clean dressing. Apply primary dressing to wound: Begin Calcium Alginate with Silver then dry gauze and roll gauze and tape. Change dressing every day. On 5/2/24 at 10:00 AM, V22, LPN, stated that she will clean R6's wound with wound cleaner or water and 4X4's, will pat dry, then apply the Calcium Alginate and cover with a non-stick pad and tape or wrap to his leg. On 5/2/24 at 10:13 AM, V2, Director of Nursing (DON), stated that she would expect the nurses to maintain a clean and/or sterile field while performing wound care, and to follow physician orders for appropriate wound care and cleaning. The Facility's Dressing Change Policy, dated 7/2007, documents To avoid introducing organisms into a wound. Procedure: 7. Set up clean area for supplies. 13. Wash your hands. 17. Cleanse wound per physician's order or use gauze and forceps or cotton applicators. 19. Apply dressing without touching wound or side of dressing. 33112 3. On 04/29/24 at 01:38 PM, V2 entered R7's room to hang / run an IV (Intravenous) of Piperacillin and Tazobacton 3.375 grams in 100 ML (milliliters) of Normal Saline (NS). V2 performed and hygiene, donned gloves, spiked the IV bag, primed a new IV line, cleansed IV catheter hub with alcohol, flushed with 10 ML of NS and attached the line. V2 set the IV pump to run at 100 ml/hr (hour). V2 removed her gloves and exited the room. V2 failed to perform hand hygiene. On 5/2/24 at 10:20 AM, V2, stated, I was talking to (R7) and just forgot. I was trying to keep him happy. On 5/1/24 at 3:30 PM, V20 stated that all staff should wash hands before putting on gloves and after removing them. The policy Hand Hygiene, dated 8/14/23, documents, Hand washing can also be used routinely in the following clinical situations: 6. Removing gloves. 4. On 04/30/24 at 9:45 AM, V9, Certified Nurse Aide, (CNA) and V10, CNA entered R17's room to lay her down and provide incontinent care. R17's pants and incontinent brief was removed. During care, V9 left the bedside to go wash her hands. V10 stayed at bedside. R17 reached down with both hands and began to scratch at her pubic area. V10 stated, Oh no get your hands out of there. V10 then assisted R17 with placing her hands on her stomach. V10 failed to wash R17's hands. On 5/2/24 at 11:13 AM, V10, was questioned why she did not offer to wash R17's hands, V10 stated, Oh my gosh, I forgot. On 5/2/24 at 11:15 AM, V1, Administrator, stated, We do not have a policy specifically toward washing of a residents hands, but I would expect staff to help and encourage residents to wash their hands when needed.

Based on interview, observation, and record review, the facility failed to provide complete incontinent care to prevent urinary tract infections for 2 of 3 residents (R17, R45) reviewed for incontinent care in the sample of 39. Findings include: 1. On 4/30/24 at 11:31 AM, V5, Certified Nurses Aide, (CNA) and V17 CNA, performed incontinent care for R45. V17 removed R45's incontinent brief. The brief was soiled with urine and a small amount of feces. V17 with wet wash cloths and peri-wash cleansed the right and left groin, V17 spread the labia and then with a wash cloth with one finger underneath the cloth wiped the urinary meatus. V17 then dried the areas. R45 was rolled over onto her right side. V17 with 3 wet wash cloths and peri-wash cleansed the rectal area and buttocks. V17 then placed a new incontinent brief and pants on R45. V17 failed to clean the pubic area, thighs, or labia. R45's Admission Information Sheet, undated, documents that R45 was admitted on [DATE]. R45's Cumulative Diagnosis Log, undated, documents R45 has diagnoses of Left Side Hemiplegia and Dementia. R45's Minimum Data Set, dated dated [DATE], documents that R45 is severely cognitively impaired, is totally dependent on staff for toileting hygiene, and is always incontinent of bowel and bladder. 2. On 04/30/24 at 9:45 AM, V9, CNA and V10, CNA entered R17's room to lay her down and provide incontinent care. R17's pants and incontinent brief was removed. R17's incontinent brief was moderately soiled with urine. V9 with a wet washcloth and peri-wash cleansed the right groin, left groin, and then wiped down the labia and the urinary meatus, flipped the cloth and repeated the process. V9 then wiped again with a wet washcloth. R17 was rolled over onto her right side. V9 wiped the rectal area with a wet washcloth and peri-wash. The washcloth had visible stool on it, with another cloth V9's rectal area was wiped again. The cloth had visible stool on it. R17 was rolled back onto her back. V10 then fastened the incontinent brief. V9 returned to the bedside. V9 and V10 covered R17 and assisted R17 with positioning. V9 failed to cleanse the rectal, buttocks, or the gluteal folds. R17's Profile Sheet, undated, documents that R17 was admitted on [DATE]. R17's Cumulative Diagnosis Log, undated, documents that R17 has diagnoses of Dementia and Expressive aphasia. R17's MDS, dated [DATE], documents that R17 is severely cognitively impaired, is totally dependent on staff for toiling hygiene, and is always incontinent of bowel and bladder. On 5/2/24 at 10:35 AM, V9, was questioned why she did not why she did not completely clean R17, V9 stated, I didn't notice any stool on the cloth. On 5/2/24 at 10:47 AM, V2, Director of Nurses, stated, During incontinent care, I expect the groin, pubic area, thighs and labia cleansed with more than just one wipe. The policy Perineal Cleansing, undated, documents, Female Resident. 12. Wash the pubic area including upper inner aspect of both thighs and front portion of perineum. a. Use long strokes from the most anterior down to the base of the labia. b. After each stroke, refold the washcloth to allow use of another area. 13. Follow same procedure for rinsing 14. Dry thoroughly. 15. Instruct or assist resident to turn to their side with tope leg slightly bent. 16. Wet the washcloth and soap, other cleansing agent. 17. Wash peri-anal thoroughly with each stroke beginning at the base of the labia and extending up over the buttocks. a. Refold the cloth, as before, to provide clean area. b. Washing should alternate side to side, ending with center anal area. 18. Rinse cloth and entire area in same sequence as above. Dry thoroughly.

Based on interview and record review, the facility failed to provide 8 hours of consecutive Registered Nurse coverage. This failure has the potential to affect all 51 residents living in the facility. Findings include: On 1/4/24 at 11:20 AM, V2, Director of Nurses, stated, We do have days that I work the floor because we are short. There are days when we do not have our 8 hours of consecutive Registered Nurse (RN) coverage. V1 stated that the facility just hired a few RN's hopefully it will get better. We usually have on days 2 nurses and 5 to 6 cna's (Certified Nurse Assistants), evenings 2 nurses and 5 cna's and nights 1 nurse and 3 cna's. The review of the Daily Staffing Schedules dated, 12/1/23 to 1/4/24, documents the facility failed to provide 8 hours of consecutive RN nursing coverage on: 12/4/23, 12/5/23, 12/6/23,12/11/23, 12/12/23, 12/18/23, 12/19/23, 12/20/23, 12/25/23, 12/26/23, 12/27/23, and 12/28/23. The facility was unable to provide a policy for RN coverage. The Long Term Care Facility Application For Medicare and Medicaid, dated 1/04/24, documents that 51 residents reside in the facility.

Based on interview and record review, the facility failed to provide freedom from inappropriate physical restraint use for 1 of 1 residents (R5) reviewed for restraint in the sample of 8. Findings include: R5's Face Sheet, undated, documents that R5 was admitted on [DATE] and has diagnoses of anxiety and Dementia. R5's Minimum Data Set, dated dated [DATE], documents that R5 is severely cognitively impaired and requires assist with ambulation and mobility. The facility supplied letter, dated 7/3/23, documents, On 6/29/23 at approximately 1:30 PM, (V2, Director of Nurses) reported to administrator that (R5) was restrained inappropriately in his wheelchair. It continues, It was noted that (R5) has been sitting his wheelchair at the nurse's station so that the staff could monitor him closely due to attempting to get up frequently without assist and was at risk for falling. It continues, (V5, Licensed Practical Nurse) then stated that she placed a gait belt around his upper abdomen loosely and his wheelchair to keep resident from standing up without assist. It continues, The facility was able to substantiated the alleged inappropriate restraint involving (R5). On 1/4/23 at 12:30 PM, V1, Administrator, stated that V5 did have a gait belt wrapped around R5 and it was looped around the wheelchair. V1 stated that V5 was educated and disciplined. V1 stated that restraining someone is not allowed. There were no other residents in the building with restraints. On 1/4/23 at 1:00 PM, V5, Licensed Practical Nurse, stated, (R5) was sitting in his wheelchair and he kept trying to get up. I had to get my evening medications passed so I was taking him down the hall with me and my cart. He had a gait belt around him already. I took the gait belt and looped it around the wheelchair handle. It was loose on him. It wasn't tight. I was just trying to keep him seated. He had it on for maybe 5 minutes. I know it was stupid. The Physical Restraint / Enabler Policy, undated, documents, To allow residents to be free of physical restraints which are not required to treat the resident's medical symptoms or as a therapeutic intervention. Physical restraints shall not be used for the purpose of discipline or convenience.

Based on interview and record review the facility failed to transcribe a physician order to the resident's Physician Order Sheet to ensure medications are administered as ordered for 1 of 1 resident (R2) reviewed for pharmaceutical services in the sample of 4. Findings include: R2's Admission Nursing Assessment, dated 5/2/23, documented diagnoses of Atrial flutter, Prolonged heart QT waves, Dementia, and Hypertension. R2's Physician's Order, dated 5/2/23, documents Eliquis 5 milligrams tablet twice a day and scheduled for 8:00AM and 5:00PM for Atrial Flutter of the heart. On 6/7/23 at 2:10 PM, V3 Licensed Practical Nurse, LPN, stated that R2 had blood in her adult incontinent brief. V3 stated she telephoned V4, R2's Physician, on 5/27/23 at 7:15 AM, regarding R2's blood in stool. V3 stated she received a verbal telephone order from V4 to hold R2's Eliquis for the 8:00AM scheduled dose and order a STAT (immediate) hemoglobin and hematocrit (H&H) blood draw and then to notify V4 when the lab results came back. V3 stated she held the 8:00 AM Eliquis scheduled dose as ordered, obtained R2's blood sample and sent off to the laboratory immediately. V3 stated the results of the H&H results came back to the facility within a few hours. V3 stated she notified V4 by telephone and received an order to continue R2's Eliquis as scheduled. V3 stated she documented on the Medication Administration Record (MAR) to hold the one single 8:00AM dose; however, failed to transcribe on R2's Physician's Order Sheet (POS), to continue/resume R2's Eliquis scheduled dosage twice a day. R2's Skilled Progress Note, dated 5/27/23 at 7:15AM, written by V3 documented, N.O (New order) received from V4. Please see POS (Physician Order Sheet). The Note documented Resident had large copious amount of blood in depends in her stool this morning. R2's, POS, dated 5/27/23, un-timed and written by V3, documents1.) STAT emergency laboratory draw for H&H blood draw. 2.) Hold Eliquis until H&H result called to V4. 3.) ok to send to ER (emergency room ) for evaluation and tx. (treatment) if another bleeding episode occur. R2's, Skilled Progress Note, dated 5/27/23 at 10:15AM, documented V4 was called regarding R2's H&H results and V4 said to continue Eliquis and watch resident if she has another bleeding episode or continues not to eat or drink all day as V4 would recommend her to be evaluated by Emergency Department and follow-up with V6, R2's physician. R2's May 2023 MAR, documented, HOLD, written in the 8:00AM check box for the Eliquis, initialized by V3, who received the order. The MAR documented that R2 received the 5:00 PM dose. The MAR documented R2 did not receive Eliquis on 5/28/23. R2's June 2023 MAR, documented R2 did not receive Eliquis on 6/1 and 6/2/23. The MAR documented HOLD on 6/2/23. On 6/7/23 at 2:46 PM, V7, LPN stated, she documented in the MAR on 6/1/23 that R2 did not receive her 8:00AM and 5:00 PM dose of Eliquis, as this was reported to her from a previous nurse reporting off work that R2's Eliquis is not to be given, and stated she wrote the word hold, on the MAR for the following day, 6/2/23. V7 stated she assumed that since R2 had rectal bleeding not to give the Eliquis (blood thinner) and failed to follow-up with the physician on clarification of the medication order and did not follow-up to look in R2's POS of a medication order change. On 6/7/23 at 3:40PM, V5, Registered Nurse for V6's (R2's Physician), stated that V6 did not order to discontinue R2's Eliquis. On 6/8/23 at 12:00PM, V1, Administrator, stated she would expect the nursing staff to document and process physicians order when received. The facility's policy and procedure, entitled, Pharmacy Medication Orders and Resident's Charts, dated 10/06, documents, Telephone orders are to be written on the special Physician's Telephone Orders form, and signed by the nurse taking the order. Whenever possible, the licensed nurse receiving the physician order should completely transcribe the order before returning the chart to the rack. Transcription includes transcribing the order to the following: The POS, MAR. All orders must include complete directions, including frequency, special directions.

Based on interview, observation and record review, the facility failed to appropriately reposition to prevent shearing and pressure, ensure pressure ulcer treatment performed as ordered and dressing intact for 1 of 2 resident (R26) reviewed for pressure ulcers in the sample of 32. This failure resulted in R26's sustaining a shear / pressure ulcer of the right buttocks and coccyx. Finding include: R26's Profile Face Sheet, undated, documents that R26 was admitted on [DATE] with diagnoses of Heart Failure, Type 2 diabetes and morbid obesity. R26's Nursing Admission Assessment, dated 2/13/23, documents that R26 had no open areas on her buttocks. R26's Minimum Data Set (MDS), dated [DATE], documents that R26 is moderately cognitively impaired, is totally dependent on 2 staff members for bed mobility and is at risk for pressure ulcers and does not have a pressure ulcer at this time. R26's Monthly weight documents that in April 2023, R26 weighed 253.4 pounds. R26's Skin Assessment, dated 3/25/23, documents, Skin to buttocks sheared r/t (related to) to small (mechanical lift) pad. R26's A. I. M. (Assessment Intercommunication Management) for Wellness, dated 3/27/23, documents, This change of condition, symptoms, or signs observed and evaluated are new skin areas on R (right) lower extremity and R hip. Nursing note; Resident noted to have several scattered opened areas not pressure related. Cleansed and creamed at this time. No infection noted. Skin Displaced. Can we have an order to cleanse and cover with cream TID (three times a day) and prn (as needed). R26's Treatment Administration Record (TAR), dated 3/28/23, documents, Apply triad cream to areas and R leg and hip every shift and prn. R26's Wound Doctor Notes, dated 3/30/23, documents that R26 has a Stage 3 Pressure Ulcer to the right buttock with full thickness. This Pressure Ulcer measures 8.5 x 13 x 0.1 cm (centimeter). Primary Dressing: Collagen powder apply once daily for 30 days; Alginate calcium with silver apply once daily for 30 days, Santyl apply once daily for 30 days. Gauze island with border apply daily for 30 days. R26's Wound Doctor Notes, dated 3/30/23, documents that R26 has a Stage 1 Pressure Ulcer of the right inferior medial hip with partial thickness measuring 3 x 13 x 0.1 cm. Dressing: Collagen Powder apply once daily for 30 days; Alginate calcium with silver apply once daily for 30 days. Dressing Gauze island dressing with border apply once. daily for 30 days. R26's Wound Doctor Notes, dated 3/30/23, documents that R26 has a unstageable Pressure ulcer of the medial coccyx full thickness measuring 1.5 x 1.5 cm x 0.1 cm. Dressing: Collagen powder apply once daily for 30 days; alginate calcium with silver apply once daily for 30 days; Santyl apply once daily for 30 days Dressing: Gauze island with border apply once daily for 30 days. The NPUAP (National Pressure Ulcer Advisory Panel) at https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf documents the definition, Unstageable Pressure Injury: Obscured full- thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. R26's Wound Doctor Notes, dated 3/30/23, documents that R26 has a Stage 1 Pressure Ulcer of the right inferior medial hip with partial thickness measuring 2.4 x 13.5 x 0.1 cm. Dressing: Skin prep once daily for 30 days. R26's Physician Orders, dated 3/30/23, documents, Cleanse area to rt (right) buttock apply Santyl, calcium alginate collagen powder change daily x (times) 30 days. Cleanse area to rt inferior medial hip apply collagen powder calcium alginate with silver change daily x 30 days. Cleanse area to coccyx apply collagen, calcium alginate with silver and santyl change daily x 30 days. R26's Wound Doctor Notes, dated 4/7/23, documents that R26 has a Stage 3 Pressure Ulcer to the right buttock with full thickness. This Pressure Ulcer measures 9.2 x 12.5 x 0.1 cm (centimeter). Primary Dressing: Collagen powder apply once daily for 22 days; Alginate calcium with silver apply once daily for 22 days. Gauze island with border apply daily for 30 days. R26's Wound Doctor Notes, dated 4/7/23, documents that R26 has a unstageable Pressure ulcer of the medial coccyx full thickness measuring 1.0 x 1.9 cm x 0.1 cm. Dressing: Collagen powder apply once daily for 22 days; alginate calcium with silver apply once daily for 22 days; Santyl apply once daily for 22 days Dressing: Gauze island with border apply once daily for 30 days. R26's Physician Orders, dated 4/7/23, documents, R buttock - DC (discontinue) santyl to area apply collagen powder calcium alginate cover with dry dressing change daily and PRN (as needed). R26's Skin Assessment, dated 4/7/23, documents, R buttocks: Stage 3 Pressure Ulcer 9.2 cm (centimeter) x 12.5 cm x 0.1 cm. Irregular Shape. Red and yellow in color with moderate drainage. R26's Skin Assessment, dated 4/7/23, documents, Medial Hip: Stage 1 pressure Ulcer 2.4 cm x 13.5 cm x 0.1 cm Irregular shape. Red and yellow in color with no drainage. On 4/13/23 at 11:03 AM, V15, Certified Nurses Aide (CNA), and V14, CNA, provided pericare for R26. R26 did not have a dressing on the right medial coccyx. At the end of care V14 and V15 pulled R26 up to the head of the bed. R26 was not lifted during this. R26 was drug along the mattress by a bed pad. On 4/13/23 at 11:26 AM, V17, Licensed Practical Nurse (LPN), provided dressing changes for R26. V17 covered the right inferior medial hip with tape. V17 failed to apply skin prep as ordered. On 4/12/23 at 2:15 PM, V1, Administrator, and V16, LPN, both stated that R26's right buttock wound just appeared one day. V1 further stated that she was getting R26 a low air-loss mattress and that it will be delivered tomorrow. On 4/13/23 at 12:20 PM, V24, Wound Doctor, stated that R26's right buttocks wound very well could have started as a shear but now it is a pressure ulcer from not repositioning. V24 stated that today the wound is 6.6 x 12.5 centimeters. V24 stated that it will more than likely take 2 months for the wound to heal and that it is very important to offload and reposition for wound healing. V24 also stated that tape should have not been put over the right inferior medial hip because she ordered skin prep for that area. On 4/13/23 at 1:45 PM, V1, Administrator, stated that R26 should be positioned in bed using a draw sheet and that 2 staff members are not enough for R26 to be turned and repositioned. The facility policy Preventative Skin Care dated revised 1/18, documents it is the facility's policy to provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep the clean, comfortable, well groomed, and free from pressure ulcers. The policy documents: #11 Practice care in moving and lifting residents. a) Prevent shearing forces during moving and transfers. b) Prevent pulling resident across the sheets. c) Avoid scratches, bruises, and skin irritation. This policy does not address treatments.

Two Deficienct Practice Statements are needed for this level due to multiple deficiencies. A. Based on interview, observation and record review, the facility failed to provide supervision, investigate falls, develop a root cause analysis and implement progressive interventions to prevent further falls for 1 of 3 residents (R30) reviewed for falls in the sample of 32. This failure resulted in R30 sustaining a head laceration which required 6 staples. Findings include: R30's Profile Face Sheet, undated, documents that R30 was admitted on [DATE] and has diagnoses of Fx (fracture) of neck of right femur, Parkinson's disease and Dementia. R30's Minimum Data Set (MDS), dated [DATE], documents that R30 is cognitively intact and requires extensive assistance of 2 for transfers, ambulation and toileting. This MDS also documents that R30 is only able to stabilize with staff assist and uses a walker and a wheelchair. R30's MDS, dated [DATE], documents that R30 is mildly cognitively impaired, requires extensive assistance of 2 for transfers and ambulation, extensive assistance of 1 for toileting. This MDS also documents that R30 is only able to stabilize with staff assist and uses a walker and a wheelchair. R30's Fall Risk Assessment, dated 12/15/22 and 3/10/23, both document that R30 is a high fall risk. R30's Care Plan, dated 12/26/22, documents, Resident has risk factors that require monitoring and interventions to reduce potential for self injury. She has weakness, unsteady gait, hx (history) of falls with recent fall with LROM (limited range of motion) rt (right) hip d/t (due to) fx and takes psy (psychiatric) meds. Medications. She is alert and follows directions and is in therapy. Review quarterly and as needed during daily care and services of Resident's plan for safety, giving verbal cues as needed to gain Resident participation in minimizing risk factors and injury. Insure adaptive devices are kept out of sight. Encourage and assist placement of proper footwear. Remind resident to lock wheelchair brakes. Observe for unsteady / unsafe transfer or ambulation and provide stand by or balance support as needed. Assist resident to clean and place prescribed eyewear when awake. Use 1 assist with ww (wheeled walker) and gait belt for all transfers. Use additional assist as needed when Resident is not feeling well, feeling dizzy or weak. Observe for and educate on proper technique and use of device. Use 1 assist with ww (wheeled walker) and gait belt for all ambulation. Use additional assist as needed when Resident is not feeling well, feeling dizzy or weak. Observe for and educate on proper technique and use of device. 1/30/23 body alarm x 24 hours. 1/31/23 poor safety awareness d/t (due to) acute condition. 3/1/23 Thirty minute checks x 24 hours. 4/6/23 30 min (minute) safety checks x 24 hours. R30's A.I.M. (Assess Intercommunicate Management) for wellness, dated 1/30/23 at 12:00 AM, documents, Res. (resident) cont (continues) to be confused @x (at times). Attempted to walk self to BR (bedroom)/ generally requiring, 2 assist, and fell to buttocks. ROM WNL (range of motion within normal limits). No injury noted (speaking about kids behind chair, etc.) c/o (complaint of) mild low back disc. Assisted to bed. R30's QA (quality assurance) Progress Note, dated 1/31/23 at 9:30 AM, documents, QA committee met and reviewed fall from 1/30/23. Res had gotten up by self and lost balance and fell . Tabs alarm applied for 24 hours. Care Plan updated. R30's Nurses Note, dated 1/31/23 at 1:15 AM, documents, Res cont to be confused has attempted to get up without assist several times. Res seeing a little boy in her room. Continue Macrobid for UTI. No adverse effects noted r/t (related to) previous fall. R30's Nurses Note, dated 1/31/23 at 10:30 AM, Res alert wit occ (occasional) confusion. Res cont to have hallucinations She is seeing children in her room Continue on Macrobid for UTI (urinary tract infection). R30's A.I.M. for wellness, dated 1/31/23 at 4:40 PM, documents, Heard a noise from restroom res was laying on back on floor. Blood was coming from back of head. States back of head hurts a little. able to move upper and lower extremities by self. Res had been sitting in recliner with alarm in place. She took alarm off and got up by herself lost balance and fell on floor. Intervention. Res sent to ER (emergency room ) for eval. R30's Nurses Note, dated 1/31/23 at 10:00 PM, documents, Called for report re (in reference to): res status. ER nurse state res was admitted with possible UTI and observation from fall. R30's QA Progress Notes, dated 2/1/23 at 9:30 AM, documents, QA committee met and reviewed fall from yesterday afternoon. Res up without assist after removing tab alarm confused and attempting to wake son up. Res has poor safety awareness d/t (due to) acute illness. Cont ABT (antibiotics) and monitoring. CP (care plan) updated. R30's Nurses Note, dated 2/1/23, documents, Res arrived back to facility by facility van. transferred 2 assist. Res has 6 staples in the back L (left) side. R30's Nurses Note, dated 2/28/23 at 3:50 PM, documents, Resident left facility at this time by ambulance. R30's Nurses Not, dated 3/1/23 at 12:00 AM, documents, No adverse effects noted r/t previous fall. R30's QA Progress Note, dated 3/1/23, documents, QA committee met to review fall from 2/28/23. Resident attempted to transfer self without assist causing fall. Resident sent to ER for eval. Care Plan updated. Resident placed on thirty minute checks x 24 hours once back in facility from ER. Care Plan updated. 4. R30's A. I. M. S for wellness, dated 4/6/23 at 6:15 AM, documents, Res was observed laying on her Rt (right) side on the floor. She slid off the end of her recliner. Res c/o (complaint of) tenderness right knee. Small red area noted to R knee. No difficulties with transfer to wheelchair. Res got up with assist r/t poor safety awareness. 30 minute safety checks initiated x 24 hours. R30's QA Committee Note, dated 4/6/23 at 10:00 AM, documents, QA committee met with therapy to review status addressing neck posturing and feeding. On 4/12/23 at 3:15 PM, V1, Administrator, stated that R30 fell the first 2 times because she was acutely ill. V1 stated that R30's son does not like R30 to be out by the nurses station so she could be watched more closely so that is why she was not put out there when she was confused with her UTI. V1 also agreed that there is not a full investigation done on each fall, a root cause analysis completed or progressive interventions put into place. The Fall Prevention policy, dated 11/10/18, documents, To provide for resident safety and to minimize injuries related to falls: decrease falls and still honor each resident's wishes / desires for maximum independence and mobility. Procedure: 5. Immediately after any resident fall the unit nurse will assess the resident and provide and care or 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. 6. The unit nurse will place documentation of the circumstances of the fall in the nurse notes or on an AIM for Wellness form along with any new interventions deemed to be appropriate at the time. The unit nurse will also place any new intervention on the CNA (Certified Nurse Assessment) assignment worksheet. 7. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the morning Quality Assurance meeting and any new interventions will be written on the care plan. 38759 B. Based on observation, interview and record review, the facility failed to provide supervision to prevent resident to resident aggression, damage of resident property, and invasion of resident rooms for 9 of 9 residents (R9, R19, R32, R40, R41, R43, R44, R47, R55) reviewed for supervision in the sample of 28. This failure resulted in R41 and R44 being fearful of R55 because of his repeated aggressive behaviors and invasion of other residents' rooms. Findings include: R55's April 2023 Physician Order Sheet documents Vascular Dementia. R55's Quarterly Psychosocial Assessment, dated 1/9/23 and 4/5/23, both document a diagnosis of Dementia, his Cognition as severe Impairment/Problem and Behavior to monitor: R55 toilets in inappropriate locations, wanders, enters bedrooms uninvited. R55's Social Service Progress notes, dated 4/5/23, documents R55 often wanders, goes in and out of other resident rooms, which agitates/upsets residents. He urinates in inappropriate places, on beds, chairs, walls, on floor. He becomes verbally/physically abusive and resistive. At times is not easily redirected. Often sits in recliner at nursing station. R55's Nurse Notes, documented the following dates of behaviors: On 1/9/23, R55 is restless, wanders, goes into other resident's rooms, urinates in inappropriate places, will go wherever he wants, wanders most of the night. On 1/16/23, R55 exit seeking, pushing on exit doors. On 2/8/23, R55 continues to frequently be up at night, goes into other resident's rooms which upsets the residents. Has been known to urinate on beds, recliners. On 2/20/23, 2/21/23, 2/22/23, documents wandering around in and out of resident's rooms, one episode, of flushing snacks down the toilet, combative with staff. Another episode, wandering, in and out of resident's rooms, and laying in their beds and eating their snacks, not easily redirected. Another episode on 2/25/23, R55 aggressively hitting staff and aggressive with a visitor. On 3/2/23, R55 this morning, wondering the halls as usual for this resident, has had aggressive behavior. This evening R55 wandering the facility and in and out of other resident's rooms. R55's Care Plan, current review dated 4/6/23, documents, R55 wanders, goes in and out of other residents rooms, goes in and out of bath/shower rooms when others are in there. often urinates inappropriate places, out in the hallway, in trash cans, was noted in another residents room and sat in their recliner voided (urinated), voided on another residents bed. Also documents undated hand written interventions to seat @ (at) ns (nursing) station, offer snack/drink. Current interventions, dated 2/23/23, for Trazadone (an antidepressant and sedative classification). R55's Facility Reported Incident form, dated 2/23/23, documented, on 2/23/23 at 6:21AM, V23, Certified Nurse Aide (CNA), witnessed R55 was standing at the nursing station and R32 was sitting in a recliner at the nursing station when R55 walked over and struck R32 in the side of the head. R55's Behavior Tracking Record, dated April 2023, documents diagnosis of Dementia with Targeted Behavior of: Combative, hitting, punching, slapping, pushing. The Goal: Will Cause no harm to self or others. The Interventions: 1:1, remove from area, divert attention, offer drink/snack. It documented this behavior occurrence 10 times on 4/12/23, however, no intervention and outcomes were documented. R55's Second Behavior Tracking log documents Wandering-goes into other residents room, attempts to exit and Third Behavior Tracking, documents, Toilets in inappropriate places, on carpet, on walls, trash cans, in recliners, on beds. On 4/11/23 at 1:10PM, V6 and V7, both CNAs, stated when R55 starts going into residents rooms, they redirect back to the recliner at the nursing station. On 4/12/23 at 9:10AM, V12 and V18, both CNA's, stated they were showering R55 in the shower room, when R55 hit V12 in the chest and V18 in the stomach. They both stated, R55 then calmed down and his shower was completed. They also stated they reported this incident to V22, Licensed Practical Nurse (LPN). On 4/12/23 at 2:00PM, V1, Administrator, stated she was not aware of this incident. On 4/13/23 at 8:51AM, V22, LPN, stated V12 and V18 reported to her the physical altercation that occurred on 4/12/23 of R55 hitting both CNAs while R55 was getting a shower. V22 stated, I got side tracked and did not report the incident to (V1, Administrator). On 4/12/23 from 8:45AM through 2:00PM, based on 15 minutes or less observation intervals, R55 was asleep in recliner in front of the nursing station no resident centered activities were provided. At 2:20PM, R55 got up out of the recliner located at nursing station. R55 walked down the hallway towards the dining area. R55 stopped and opened a resident's closed door, stepped in the room, and walked out of the room. There were no staff present in the area during this time. On 4/11/23 at 2:05PM, V6, CNA, stated that earlier today, R55 went into R9 and R40's room, which they were not in their rooms at the time, and was witnessed and reported by R44. V6 stated that R55 peed, in their trash can that is between the two resident's beds. On 4/12/23 at 1:40PM, R19 stated she saw R55 enter R9's and R40's room, as she can see the room from her recliner. R19 stated R55 was in that room for a while, she activated her call light to alert the nursing staff that R55 was in R9's and R40's room. R19 stated she heard the nurse state that R55 had urinated in their trash can in their room. R19 states, Please stop him from going into our rooms. R19 stated she was asleep in her recliner, when she woke up from her chair and saw R55 laying in her bed, she yelled for help and now she keeps her door shut to keep R55 from coming into her room. On 4/12/23 at 9:15AM, R41 stated R55 came into her room urinated in her dresser drawer that was opened and splattered on her purse that was on the floor in front of the dresser. R41 stated she now shuts her door to keep R55 out from entering her room. R41 states, I feel scared because he has hit nurses. On 4/12/23 at 9:20AM, R44 stated R55 has come in the room and urinated in the trash can that is located at the bedside. R44 also stated R55 has been known to hit staff, so they are scared to agitate him. On 4/12/23 at 9:25AM, R43 stated R55 comes in the room, and now R43 has the curtain pulled, which sometimes seems to help with R55 coming into room. On 4/12/23 at 8:56AM, R47 states, he peed in my chair and wall, I keep door shut now because of R55. When I sleep at night in bed, I keep my shoes at the head of my bed, because I have had to throw them at him to get him out of my room, I don't know why we have to put up with his issues. R47 also stated, I shut my door when I go to the dining room to eat, and I sit at a dining room table to where I have clear view of my room. On 4/13/23 at 9:10AM, V1, Administrator, stated that 1 on 1 is considered, as needed with R55 and she would expect an intervention to be specific to his behaviors.

Based on observation, interview and record review the facility failed to provide a Registered Nurse (RN) 8 hours a day seven days a week and failed to provide a Director of Nursing (DON). This has the potential to affect all 55 residents at the facility. Findings include: On 4/10/2023 at 10:00AM, there was no RN or DON on duty at the facility. The facility's March 2023 Nursing Schedule documents no RN coverage on 3/2, 3/3, 3/6, 3/7, 3/8, 3/11, 3/12, 3/14, 3/15, 3/16, 3/17, 3/18, 3/19, 3/20, 3/21, 3/22, 3/23, 3/26, 3/29, 3/30 and 3/31. The April 2023 Nursing Schedule documents no RN coverage on 4/1, 4/2, 4/4, 4/5, 4/8, and 4/10. The April 2023 Nursing Schedule has no documentation of DON from 4/1-4/12/2023. On 4/11/23 at 03:07PM, V1, Administrator, stated that the DON resigned on 3/31/2023. V1 stated the facility does have an ad online for a RN and DON. V1 stated the facility has 2 RN's on staff but one RN is per diem. On 4/13/2023 at 9:23AM, V1, Administrator, stated that the facility should provide RN coverage 8 hours a day 7 days a week and a DON. On 4/13/2023 at 9:36AM, V1 stated the facility does not have a policy on staffing but follows state guidelines. The facility's Resident Census and Conditions of Residents, CMS 672, dated 4/10/2023, documents there are 55 residents living in the facility.

Based on interview, observation and record review, the facility failed to ensure a medical brace was applied for 1 of 1 resident (R13) reviewed for medical braces in the sample of 32. Findings include: R13's Profile Face Sheet, undated, documents R13 was admitted on [DATE] and has diagnoses of Dementia and Difficulty walking. R13's Minimum Data Set, dated dated [DATE], documents that R13 is severely cognitively impaired, requires extensive assistance of 2 staff members for transfers, supervision for ambulation in the room, is unable to stabilize without staff assistance and uses a walker. R13's Left Ankle X-ray, dated 4/6/23, documents, Impression: Healing distal fibular fracture. In handwriting on the X-ray signed by V21, Physician, it documents, Continue CAM (Controlled Ankle Movement) Walking Boot and Partial Weight Bearing. R13's Physician Orders, dated 4/7/23, documents, cont (continue) to wear CAM walking boot. On 4/10/23 at 12:10 PM, R13 is eating lunch in her room while sitting in her recliner. R13 is not wearing her CAM walking boot. R13 stated that she does have to wear it anymore. On 4/11/23 at 10:00 AM, V19, R13's Power of Attorney and V20, R13's sister are in R13's room visiting. V20 is putting R13's CAM walking boot on. On 4/11/23 at 10:00 AM, V20 stated that the boot was next to her recliner and she stated that the boot was full of trash. V19 stated that R13 must wear the boot when she is up but not while she is in bed. V19 and V20 both stated that when they visited on Saturday, R19 did not have her boot on and they had to put it on her. V19 and V20 both stated that R13 was up in her recliner when they saw her. On 4/12/23 at 4:00 PM, V21, Physician, stated, (R13) should be wearing her boot. The boot keeps her ankle stable and does not allow movement in the ankle. She has a very slow healing fracture in her ankle. She can have it off for a few hours for things like hygiene and things like that but she should have it on when in bed and up. (R13) is not alert or orientated enough to know that she needs it and to wait for help if she wants to get up. I have also went in the evening and found her sitting in her recliner without it. I have told the staff that she needs to wear it. I don't believe her not having it on has hurt her because I always examine the ankle whenever I am in the building and she gets weekly X-ray's. On 4/12/23 at 2:30 PM, V10, Therapy Director, stated that R13 has completed therapy at this time because she has reached her maximum potential of what she can do with the CAM walking boot on and partial weight bearing status. V10, stated, (R13) should have the boot on when she is awake and up. On 4/13/23 at 9:08 AM, V1, Administrator, stated that R13 should have her boot on when she is awake and she can have it off when in bed. On 4/13/23 at 2:50 PM, the facility has failed to provide a policy and procedure for braces to review.

Based on observation, interview and record review, the facility failed to perform hand hygiene and change gloves to prevent cross contamination for 2 of 14 residents (R26, R45) reviewed for Infection Control in the sample of 32. Finding includes: 1. On 4/11/23 at 1:06PM, V6 and V7, Certified Nurse Assistants (CNA), performed incontinent care for R45. V7 wore the same gloves throughout the incontinent care. 33112 2. On 4/12/23 at 11:03 AM, V15 CNA and V14 CNA provide incontinent care for R26. V15 changed gloves 2 times without hand hygiene in between. V14 changed gloves 1 time without hand hygiene in between. On 4/11/23 at 3:30 PM, V1, Administrator, stated that hands should be washed in between glove changes. The facility policy handwashing, dated 12/7/18, fails to document when hands should be washed.

Based on interview and observation, the facility failed to secure medical health information. This failure has the potential to affect all 44 residents living in the facility. Findings include: On 05/03/22 at 2:00 PM, V9, Ombudsman, stated, I have a concern about the Personal Health Information (PHI) being left out in binders in the east hall small dining/activity room. We have our resident council meetings in that room and the binders are always left out. On 05/03/22 at 2:13 PM, The northeast activity room has 3 binders laying on a table. The outside of the binders has a list of resident names. The inside of binder contains resident flow sheets related to Activities of Daily Living, Restorative Nursing and Behavior Tracking. These documents include information about medication, assistance needed and behaviors. The room has an open door, and no staff are present at this time. On 05/3/22 at 3:30 PM, V10, Certified Nurse's Aide (CNA), stated that the binders in the activity room are the CNA charting books. V10 stated that usually they are kept at the nurse's station. On 05/4/22 at 1:00 PM, V1, Administrator, stated, The binders should not be left out in the open where anyone can look at the information. On 5/5/22 at 12:16 PM the facility had failed to provide a policy and procedure for privacy and medical records. The Resident Census and Condition of Residents, CMS 672, dated 5/2/22 documents that the facility has 44 residents living in the facility.

Based on observation, interview and record review the facility failed to provide a Registered Nurse (RN) 8 hours a day seven days a week and a Director of Nursing (DON) since 4/1/2022. The has the potential to affect all 44 residents at the facility. Findings include: The facility April 2022 Nursing Schedule Sheet, documents on 4/5/2022 the facility only had RN coverage for 6 hours. The Schedule sheet documented on 4/13/2022 there was an RN scheduled for only 4 hours and on 4/14/2022 for only 6 hours. The schedule documented there was no RN coverage on 4/15/22. The schedule documented on 4/20/22, there was a RN scheduled for only 4 hours. Throughout the survey, there was no employee/RN designated as the DON. On 5/4/2022 there was no RN observed on duty at the facility. The facility's May 2022 Nursing schedule sheet documented on 5/4/22 there was no RN scheduled as the RN called off. On 5/4/2002 at 12:05 PM, V1, Administrator, stated that the facility has not had a DON since 4/1/2022 when the previous DON quit. V1 stated there has not been a RN assigned to do the DON duties. V1 stated the duties are being done by 2 Licensed Practical Nurses (LPNs) and herself. V1 stated there is not an RN on duty today because the RN scheduled called off. On 5/5/2022 at 12:45 PM V1, Administrator stated the facility does not have a staffing policy but follows stated guidelines. The facility's Resident Census and Conditions of Residents form, CMS 672, documented the facility has 44 residents living in the facility.

Based on interview and record review, the facility failed to ensure as needed (PRN) orders for [CONDITION(S)] medications were only prescribed for 14 days unless medically necessary for 4 of 8 residents (R2, R11, R12, R28) reviewed for medications in the sample of 23. Findings include: 1.R2's Physician Orders, dated April 2022, documents, [MEDICATION(S)] 0.5 mg (milligram) Tablet. Take 1 tablet every 4 hours PRN (as needed) anxiety/restlessness. Start date of 1/10/22. There was no documentation in R2's medical record regarding the documented justification/rationale for the extended use of the PRN [MEDICATION(S)]. On 05/04/22 at 10:50 AM, V1 Administrator, stated that R2 is a (local hospice agency) patient and that she knows the (local hospice agency) is to write the PRN prescription for 14 days and then reevaluate the need for the medication, but they won't do that. 2. R11's Physician Orders, dated May 2022, documents, [MEDICATION(S)] 0.5 mg Tablet. Take 1 tablet every 4 hours PRN anxiety. Start date of 2/8/22. There was no documentation in R11's medical record, V21, R11's Physician, had documented the justification/rationale for the extended use of the PRN [MEDICATION(S)]. 3. R12's Physician Orders, dated May 2022, documents, [MEDICATION(S)] 0.5 mg tablet. Take 1 tablet by mouth every four hours as needed (anxiety and agitation). May crush. Start date of 2/10/22. There was no documentation in R12's medical record, V21, R12's Physician, had documented the justification/rationale for the extended use of the PRN [MEDICATION(S)]. 4. R28's Physician Orders, dated May 2022, documents, [MEDICATION(S)] 0.5 mg Tablet. Take 1 tablet by mouth every 4 hours as needed for anxiety. Start date of 3/14/22. There was no documentation in R28's medical record, V22, R28's Physician, documented the justification/rational for the extended use of the PRN [MEDICATION(S)]. The facility policy [CONDITION(S)] Medication Policy, dated 11/28/17, documents, Type of PRN order: PRN orders for psychotropics medications, excluding antipsychotics. Time Limitation: 14 days. Exception: Order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order. Required Actions: Attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicated a specific duration.

Based on interview, observation and record review, the facility failed to encourage residents to wear face masks to prevent the spread of COVID-19 per facility policy and perform hand hygiene before donning gloves to prevent the spread of infection for 4 of 16 residents (R2, R6, R12, R26) reviewed for infection control in the sample of 23. Findings include: 1. On 5/2/22 at 12:39 PM, R12 was in the hallway. R12 was not wearing a mask. V11 Certified Nurse Aide (CNA) and V10 CNA took R12 to the restroom to toilet. V10 and V11 both donned gloves without hand hygiene. V10 and V11 transferred R12 from her wheelchair to the toilet. V7 CNA entered the restroom to assist. V7 donned gloves with no hand hygiene. R12 urinated. R12 was assisted to the standing position and V10 wiped her and pulled her incontinent brief and pants up and assist R12 back into the wheelchair. V10 then removed her gloves and performed hand hygiene. At the end of care neither V10 nor V11 encouraged R12 to wear a mask. On 5/5/22 at 10:00 AM, V2 Assistant Director of Nurses, stated, Staff should perform hand hygiene before donning gloves. The facility policy Hand Hygiene, dated 12/7/18, did not address/document performing hand hygiene before donning gloves. 2. On 5/3/22 at 9:10 AM, R2 was in the hallway after breakfast. R2 was not wearing a mask. R2 was taken to restroom by V11 and V10. R2 was not encouraged to wear a mask after care. 3. On 5/5/2022 at 9:08 AM R26 was in hallway in reclining chair without a mask on. V7 CNA was pushing R26 down hall and did not encourage R26 to put on mask and no mask observed on R26's chair. 4. On 5/5/2022 at 9:10 AM R6 was in hallway in wheelchair with no mask on an no staff encouragement to don mask. On 5/5/2022 at 9:05 AM V1, Administrator, stated that the facility has tried to get resident to wear face masks, and some will not. V1 stated she would remind staff to encourage residents to wear face mask. The facility's policy COVID-19 Control Measures, revised 3/25/2022, documents if residents are out in the facility or in the presence of others, face coverings should be worn if tolerated, regardless of vaccination status. The policy documents if a resident is unable to tolerate a face covering, then a face shield can be utilized.

Based on interview and record review, the facility failed to ensure residents call lights were answered timely to promote resident's dignity for 4 or 10 residents, (R4, R29, R38, R43) reviewed for dignity in the sample of 23. Findings include: 1. R29's Minimum Data Set, (MDS), dated [DATE], documented, R29 is cognitively intact and requires assistance of one facility staff with transfers and toileting. On 5/2/22 at 11:00AM, R29 stated that he waits to activate his call light because he knows that around 7:00PM, the staff are busy getting other residents to bed and at 11:00 AM, the staff are getting residents ready to transfer to take to the dining room. R29 stated he has learned during these times is not the time to request assistance from staff. 2. R43's MDS, dated [DATE], documented R43 has very mild impaired mental cognition and requires assistance with emptying a urinal container, [CONDITION(S)] appliance and transfers with one facility staff. On 5/2/22 at 9:40AM, R43 stated that about a couple months ago, he was eating in his room, as he always eats his meals in his room, when he got up from his recliner, his legs went out and lowered himself to the floor. R43 stated, he activated his call light and stated it was 1 hour and 20 minutes before someone came in his room. R43 asked the staff member who addressed his call light, what was the delay and the staff member stated she was at the other end of the hall assisting residents. 3. R4's MDS, dated [DATE], documented R4 has impaired mental cognition and, requires assistance with set -up with bathing and dressing. On 05/02/22 at 2:33PM R4 stated she uses a walker, but the staff place the walker away from reach. R4 stated she will then walk over to the walker location to use it. R4 stated she activates her call light in the evening hours, requesting a pain medication for her knee pain and she may have to wait longer than 20 minutes before staff enter her room. R4 continued to state that, staff answering of the call lights are worse during the evening hours. 4. R38's MDS, dated [DATE], documented R38 is cognitively intact and requires no assistance from staff with her care. R38's Care Plan, dated 5/10/21, documented R38 requires assistance with bowel and bladder incontinence. On 5/2/22 at 9:25AM, R38 stated she requires assistance with her incontinence and wears incontinent briefs. R38 continued to state during the evening hours from 7:00PM to 11:00PM, she activates call light for assistance and waits longer than 15 minutes. R38 states the staff say, I am sorry, I am working down the other hall. The Facility's, Grievance/complaint Report, dated 1/7/21, 2/4/22, 4/22/22, documented call lights requested to be answered sooner, call lights stay on longer than they should, and call lights remain a problem.

Based on observation, interview and record review, the facility failed to assess and identify, treat, and provide turning and repositioning for 2 of 4 residents (R15, R45), reviewed for pressure ulcers in a sample of 24. This failure resulted in R45 developing facility acquired unstageable pressure ulcers to his buttock. Findings include: 1. R45's Physician order [REDACTED]. R45's Minimum Data Set ((MDS) dated [DATE], documents that R45 has severe impaired cognitive skills for daily decision making; indicating he is moderately impaired, having an indwelling catheter and always incontinent of bowel. The MDS further documents R45 requires total assistance from staff with bed mobility, transfers and personal hygiene. R45's Braden Scale for Predicting Pressure Ulcer Risk dated 5/22/19 documents 13, indicating high risk for skin breakdown. R45's Care Plan, initiated on 11/25/17, documents that he is at risk for skin breakdown, Certified Nurse's Aides (CNAs) will conduct skin checks daily during care and baths/showers and staff report any new skin concerns to the doctor for treatment and follow-up. The Care Plan further documents R45 had a Stage 2 pressure ulcer on his right buttock on 2/12/19 that was healed on 2/27/19 and had a Stage 2 pressure ulcer to his left buttock on 2/12/19 that was resolved on 3/5/19. R45's Wound Documentation notes for R45, dated 4/3/19, documents Skin w/d (warm and dry), no excoriated areas noted, OA (open area) to R (right) outer heel that measures 1 by 1.4 centimeters (cm). 0 (no) other concerns noted. R45's Nurse's Notes dated 4/10/19 at 9:15AM, document in part, Resident noted to have pressure areas to bilateral buttocks. Doctor notified for treatment orders. Resident to lay side to side in bed. Spoke with wife about fresh fruit for snacks. Special cushion provided for wheelchair. Care plan updated. The Nurse's Notes did not describe the size, color or condition of the pressure ulcers. R45's Care Plan dated 4/10/19 documents R45 having bilateral Stage 2 pressure ulcers to his right and left buttock. R45's Treatment Administration Record (TAR) dated 4/12/19 documents Area to right buttock 4.5 X (by) 3.0 cm. left (lower) buttock 2.0 X 3.0 cm. The TAR documented the areas were yellow and black with moderate drainage. R45's TAR entry, dated 4/22/19, documents R45's pressure ulcer to right buttock measured 4.5 cm by 3.0 cm and the pressure ulcer on his left buttock 4.0 cm by 1.5 cm. The TAR documented the pressure ulcer was unstageable. R45's TAR entry, dated 4/30/19, documents R45's pressure ulcer to his right buttock measured 5.0 cm by 3.0 cm and his left buttock pressure ulcer measured 3.7 cm by 1.5 cm. The TAR documented the pressure ulcer was unstageable. Interdisciplinary Team (IDT) notes dated 5/1/19, documents the IDT met and R45's skin was reviewed, and the findings were that each of R45's areas to each buttock were worsening. The documentation further documents the doctor was notified and a referral was received for R45 to go to the wound clinic. Wound clinic notes dated 5/7/19, documents in part R45 having unstageable pressure ulcers to his right and left buttocks. The facility matrix dated 6/16/19, documents R45 has a Facility acquired pressure to right and left buttock discovered on 4/12/19. There is no entry noted for R45's pressure ulcers for 4/10/19. On 6/20/19 at 2:00PM, V2, Director of Nursing (DON), stated the facility was not aware of R45 having pressure ulcers until they were open on 4/10/19, but were not measured until 4/12/19, and that the pressure ulcers should have been measured at the time they were noted. V2 stated she could not explain why R45's pressure ulcers weren't discovered prior to becoming unstageable. The Facility Policy entitled Decubitus Care/Pressure Areas, revised on 1/18, documents Policy: It is the policy to ensure a proper treatment program has been instituted and is being closely monitored. The Policy documents Procedure: 1) Upon notification of skin breakdown, the QA (Quality Assurance) form for Newly Acquired Skin Condition will be completed and forwarded to the Director of Nurses. 2) The pressure area will be assessed and documented. 3) Complete all areas of the Treatment Administration Record or Wound Documentation Record. i) Document size, stage, site, depth drainage, color, odor, and treatment. The Policy further documents in part, 5) Documentation of the pressure area must occur upon identification. 2. On 6/17/19 at 11:43 AM, R15 was asleep sitting in his high back chair in a reclining position in his room, leaning to the left side with no positioning devices in his chair. At 3:13PM, R15 remained up in his chair. On 6/17/19 at 3:13PM, V16, CNA, stated R15 had been sitting up prior to the noon meal. On 6/18/19 at 11:50PM, R15 was noted sitting in his high back chair in a reclining position at the nurse's station. R15 had no positioning devices in his chair. On 6/18/19 at 2:10PM, surveyor asked V7 and V17, CNAs, how long R15 had been sitting in his high back chair. V7, CNA, stated in part, He's been up since 11:40 (AM), so yes, longer than 2 hours. After R15 is then transferred from his chair to bed by V7 and V17. Once in bed, R15 was rolled onto his right side and his pants and incontinent brief were removed. R15 had deep red creases on his left buttock, extending down to his mid right thigh. When R15 was rolled onto his left side, deep red creases were noted extending from his right mid back down to his right mid-thigh. R15's MDS, dated [DATE], documents R15 having severely impaired Cognitive Skills for Daily Decision Making. The MDS further documents R15 requiring total dependence on staff for Activities of Daily Living (ADLs). R15's Pressure Ulcer Risk assessment dated [DATE], documents R15 scoring a 12, indicating a high risk for skin breakdown. The Assessment further documents in part R15, Requires moderate to maximum assistance in moving. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. R15's Care Plan dated 4/19/19, documents in part, R15 having [MEDICAL CONDITION] and Alzheimer's. The Care Plan further documents R15 having self-care deficits and dependent on staff for ADLs, being incontinent, and to use pillows for positioning and is to be turned at least every 2 hours and as needed. On 6/19/19 at 10:51 AM, V2, DON, stated she would expect for staff to turn and position R15 even while up in a chair timely. On 6/20/19 2:30PM, V1, Administrator, stated in part it is the expectation for staff to reposition residents at least every 2 hours, and depending on the resident's condition, it may be more frequently, but at the very least every 2 hours. V1, Administrator, further stated the facility did not have a specific policy on turning and positioning for dependent residents. Facility Policy entitled Pressure Sore Prevention Guidelines, revised on 11/12, documents in part, Policy: To provide adequate interventions for the prevention of pressure ulcers for residents who are identified as HIGH or MODERATE risk for skin breakdown as determined by the Braden Scale. The policy also documents as an intervention, Turn and reposition every two hours for those residents with moderate or high-risk potential for pressure ulcers and Turning and positioning may be more often than every 2 hours for high risk.

Based on observation, interview and record review, the facility failed to provide adequate pain management for 2 of 9 residents (R7 and R13) reviewed for pain; and failed to timely identify, assess and treat wounds for 2 of 2 residents (R3 and R12) reviewed for wound care and failed to integrate Hospice Care Plan with facility Care Plan for 1 of 1 resident (R5) reviewed for Hospice Services in the sample of 15. This failure resulted in R7 not receiving effective pain management prior to Therapy and was discontinued from Therapy due to lack of progress. Findings include: 1. According to the Admission Record, R7 was readmitted to the facility on [DATE] following hospitalization for a [MEDICAL CONDITION]. R7's June 2013 Physician order [REDACTED]. R7 also has an order dated 5/18/13 for [MEDICATION NAME] 5-325 take 2 tablets by mouth every 4 hours as needed (PRN). R7's Care Plan dated 10/23/12 documents R7 has alteration in Comfort/Pain related to complaints of pain to left hip due to recent repaired left [MEDICAL CONDITION]. She is alert but does not always voice her needs. She takes scheduled and prn pain meds. Care Plan approach in part, Complete pain assessment prn, monitor for signs and symptoms of pain and report if worsening or no improvement. There is no current pain management plan in place that includes medication is given before therapy to ensure R7 is at optimum comfort level when participating in therapy. R7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The Pain Management Flow Sheet has no documentation for 6/2/13 and documents R7 had no pain on 6/3/13 through the AM of 6/9/13, there is no documentation on 6/10/13 and 6/11/13 for [MEDICATION NAME] given at 12:30AM for complaints and yelling and was effective with R7 sleeping. As of 6/7/13, R7's last documentation on the PAIN Assessment of 5/27/13 documents R7 states both legs hurt her frequently but fails to include nonverbal signs of pain. She takes scheduled and PRN pain medication. R7's Physical Therapy (PT) Evaluation of 5/20/13 documents the reason for referral is R7 fell and fractured the left hip for the second time. Prior therapy with previous fracture had good results. R7 is unable to rate pain and does complain of pain in the left hip with movement. There is no indication that PT and nursing discussed pain management that included pre-medicating R7 prior to therapy so she was comfortable. On 6/5/13 at 1:50PM, R7 was in Physical Therapy and yelling, "No, no" when E17, Physical Therapy Aide (PTA) and E8, Certified Occupational Therapy Aide (COTA) attempted to stand her. R7 was pushing them away and rubbing her legs and rocking repeatedly stating her leg hurt. R7 kept rubbing her legs and stating she hurt. They left her alone for a few minutes and then went back and tried to stand R7. R7 screamed out in a high pitch scream when they attempted to transfer from her wheel chair to a standing position. On 6/6/13 at 11:35AM, R7 complained of terrible pain to her leg and pointed to the left thigh. At 12:15PM, E19, Licensed Practical Nurse (LPN), gave R7 PRN [MEDICATION NAME]. E19 stated R7's pain is usually controlled but today is different. Nurses Notes of 6/3/13 document R7 needed much encouragement to participate with PT today. Yelled out, kicked etc. during therapy. Yet MAR indicated [REDACTED]. Nurses Note of 6/6/13 at 2AM documents R7 does not stand well. Unable to orientate to tasks Yell after supper until bedtime. Nurses Note of 6/7/13 at 1 PM documents R7 participates in therapy. Started yelling/ moaning again after lunch. PRN pain med administered. Again no comprehensive pain assessment was done on R7. On 6/7/13 at 2PM, E23, Physical Therapist (PT) stated R7's behaviors were worse and she was fighting therapy, yelling all the time. R7 had therapy after her first [MEDICAL CONDITION] and did OK. E23 stated R7 yells and will yell if just sitting there. She could be in pain. E23 stated she thought R7 was getting pain medication prior to therapy to help with pain control. E23 stated they were going to discontinue R7 from Therapy due to lack of progress. E23 also stated she had never talked with nursing about pre-medicating R7 to ensure she was comfortable during therapy. In interview on 6/7/13 at 2:50pm, E18 LPN stated she knew R7 well. E18 stated R7 yelled and moaned after her first fall but continued to participate in therapy. When asked about R7's current pain, E18 stated that R7 had pain medication scheduled three times a day after the first fall and that seemed to keep her fairly comfortable. E18 stated R7 now only has it ordered twice daily. E18 stated she attributes all of R7's yelling to anxiety and didn't know she was complaining of pain in therapy. E7 stated she does not know when R7 has therapy nor has she talked to any of the therapist in regards to medicating before therapy. On 6/7/13 at 3pm, E24 CNA was interviewed regarding R7 and stated she was familiar with her care. E24 stated R7 use to ambulate independently then fell and went through therapy. E24 stated she did well in therapy and then fell again on a home visit refracturing her hip. E24 stated R7 is not doing as well following this second fall as she doesn't want to participate in therapy. E24 stated she does yell and complain of leg pain, drags her leg and refuses to bear weight during transfers now. E23 provided a list documenting R7 had Physical Therapy on 6/4/13 from 4:41PM to 5:25PM, on 6/5/13 from 1:37 PM to 2:22PM and 6/6/13 from 12:20PM - 12:56PM. R7 also had Occupational Therapy on 6/5/13 from 7:45AM to 8:07AM and on 6/6/13 from 2:11 - 2:29PM. R7's MAR indicated [REDACTED]. On 6/11/13 at 7:55AM, E1, Administrator, stated that Therapy had given notice that R7 was being discontinued from Therapy. The facility had done X rays on R7 and Xray results did not show any problems. E1 stated R7's Physician did order to recheck Xray in one week if pain persists. X ray report of 6/8/13 documents, "Increased pain two hip pinnings....No radiographic evidence of acute fracture or dislocation. If symptoms persist, consider follow-up radiographs in order to evaluate for initial radiographically occult fracture. 2. According to the Admission Sheet, R3 was admitted to the facility on [DATE] from the hospital. The intital MDS identifies R3 as having short/long term memory deficits with moderate cognitive impairment and requiring extensive assist of two staff for most activities of daily living. The MDS also identifies R3 as being morbidly obese, and frequently incontinent of bladder. The physician's orders [REDACTED]. On 6/6/13 at 9:35am, E13 and E14, Certified Nurses Aides (CNA) transferred R3 to the toilet. As he was sitting on the toilet, the CNA's removed a slightly wet paper incontinent brief. R3 had a folded pillow case hanging out from under his pendulas abdominal apron/fold that extended from one side to the other. When interviewed at the time about this, the CNA's stated that he had a rash under his abdominal fold and they put the pillow case under it to keep it from rubbing. When asked to see the abdominal area, R3 moaned and stated "Ohhhhh" as the skin was lifted exposing a extremely reddened area across the width of his abdomen and extending down into his groin area. The CNA's cleansed R3's inner buttocks but provided no cleansing to his periarea/groin and/or penis/scrotum, or inner thighs. At 9:45am while R3 was still sitting on the toilet, E12 Licensed Practical Nursed (LPN) came in with a jar of barrier cream and after removing the pillow case, wiped both sides with a wet wash cloth that had no cleansing agent on it. E12 then applied the white barrier cream with the same soiled gloves and replaced the pillow case with a clean one before leaving the bathroom. She did not observe the area and stated that it was difficult to see because of the large fold. R3 again moaned and groaned stating "ohhhh" as she wiped the reddened areas and applied cream. The CNA then placed a folded pillow case under the abdominal fold and transferred him back to his chair. E12, LPN, was asked at 10:20am in interview to describe R3's abdominal fold/groin area since the area was not completely observed during the treatment and responded "gaulded, not yeasty looking." The nurses notes contained no assessment of the area that included size, wound bed, color, drainage. At 3:30pm on 6/6/13, E3, LPN was in R3's room assessing his abdominal fold excoriation. He was noted to have deep red excoriation that was 4 inches wide from side to side under his abdominal fold between his umbilicus and pubis which extended down into his groin area and inner thighs. He had a open area right inner thigh which was dark in color and another area inner left thigh which was white. His scrotum and penis were red, [MEDICAL CONDITION] and gaulded as well and he complained of pain and discomfort as they were moving him about. E3 agreed that R3 needed to be cleansed well after incontinent care and stated the physician would be called for a treatment. The nurses notes reviewed from admission 5/23/13 through 6/6/13 at 12am, reflect nothing in regards to excoriation and/or redness in R3's abdominal fold. The nurses notes written at 12am on 6/6/13 include documentation "MD (medical Doctor) will be made aware of reddened areas" but fails to document what areas and also fails to include an assessment of the reddened areas identified. On 6/6/13 at 9:40am, the nurses notes document "barrier cream applied to abd (abdominal) fold + groin" but again fails to identify any redness and/or excoriation. At 5pm on 6/6/13, after E3 was observed assessing R3's abdominal fold, a brief entry was written into the nurses notes that documented only the small area inner left thigh which read "small open area noted to L (left) inner thigh whitish in color 0.2 x 0.2cm (centimeters) 0 drainage noted" and the physician was made aware. The assessment included no information on the deep reddened areas noted throughout his periarea, inner thighs and scrotal area. A new order was received for barrier cream daily and PRN. The assessment also failed to include measurements. On 6/7/13, during the daily meeting with the facility, E3 stated the physician had ordered [MEDICATION NAME] for the abdominal fold. Nurses notes written on 6/7/13 at 8am also identify bright red drainage from R3's penis. Daily Skin Checks documented on R3 every shift for 6/1/13 thru 6/6/13 showed no areas noted. Interview with Z5, (R3's son) on 6/7/13 at 1:15pm indicated that his father did complain of pain of "his bottom" at times. According to the Skin Condition Monitoring policy dated 01/02, the facility is to provide proper monitoring, treatment and documentation of any resident with skin abnormalities. Under Procedure, the nurse, upon notification of a [MEDICAL CONDITION], assess and document: location of area to be treated, frequency of how often, how area is to be cleansed, and a stop date. Documentation of the area itself, according to the policy, is to include" size, shape, depth, color and presence of granulation and or necrotic tissue. The policy entitled "Preventative Skin Care" dated 10/06 indicates that the facility will provide preventative skin are through repositioning and careful washing, rinsing, drying, and observation of the residents skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers. 3. On 06/05/13 from 11:30 AM to 2:00 PM, R12 was observed sitting up in a wheelchair. At 2:00 PM, E5 and E20, Certified Nurses Assistant's (CNA's), were observed to transfer R12 from the wheelchair to the bed per mechanical lift. When R12's incontinent brief was removed, it was observed that the brief was saturated with urine and had a small amount of stool on it. There was an open area observed in the crease of the buttocks near the coccyx area with fecal matter near the wound. The wound was 2 cm x 1.5 cm covered with yellow-white tissue with raised reddened skin surrounding wound. There was no dressing observed on the wound. E20, CNA, stated that R12 "had one (dressing) on for awhile, but she didn't know if he still needed one now." E5 checked the inside of the incontinent brief and no dressing was found. On 06/06/13 at 12:10 PM, E13 and E21, CNA's, were observed during transfer and incontinent care for R12. When R12's pants were removed, his incontinent brief was soiled with urine and a small amount of stool. There was a wrinkled up bandage that was hanging off R12's left buttock, not covering the wound. E13 removed the bandage and incontinent care was done. During an interview conducted on 06/05/13 at 2:30 PM with E12, Licensed Practical Nurse (LPN), it was determined that E12 does not do dressing changes for R12. E12 stated that each nurse on varying shifts is assigned specific residents and is responsible for those dressing changes. E12 stated that in the event of a dressing becoming soiled or needing to be changed, the nurse on duty would be the one to do the dressing change. E12 stated that she thought R12's dressing change was changed every three days, but did not know the status of the wound at this time. E12 stated that she is the nurse on duty for the west hall where R12 is located. The physician's orders [REDACTED]. The Minimum Data Set (MDS), dated [DATE], documented R12 is severely cognitively impaired requiring extensive assistance with at least two staff for bed mobility, all transfers, bathing and toilet use. The MDS also documented R12 is incontinent of bowel and bladder. The Care Plan, dated 03/29/13, documented R12 is at risk for skin breakdown due to incontinence. The Care Plan does not include any information regarding an open area on the sacrum as of 6/7/13. The Braden Scale for Pressure Ulcer Development, dated 04/23/13, scored R12 at 19, which is a moderate risk for development of pressure ulcer. Nurses notes, dated 04/26/13 at 4:30 PM, documented "New Order (N.O.) processed for treatment to residents left buttocks..." On 05/09/13 at 2:30 PM, nurses note documented "Open area measures 0.5 x 1.0 cm. Purple to peri wound. Raised and firm to touch." On 05/08/13, an Evaluation (Eval) sheet documented "acquired left inner buttocks measuring 0.6 x 0.5 cm with moderate sero-sanguinous exudate, hardness/induration, cleanse daily, apply dry dressing, keflex for 7 days, appearance of a boil." On 05/16/13, an Eval sheet documented "1.0 x 0.5 cm with moderate sero-sanguinous exudate, [DIAGNOSES REDACTED]/redness-non-blanchable and hardness/Induration." On 05/23/13, an Eval sheet documented "1.3 x 0.6 cm with light sero-sanguinous exudate, [DIAGNOSES REDACTED]/redness-non-blanchable and hardness/Induration, granulation and 30% slough." On 05/30/13, an Eval sheet documented "1.5 x 0.7 cm with sanguinous exudate, 50% slough, firm to touch." There were no nurses notes or documentation provided of when the area on the sacrum opened and drained or that documented an assessment done at that time that described the open area. A POS (Telephone Order - T.O.) and Treatment Record, dated 04/26/13, documented "left buttocks treatment: cleanse daily and apply hydrogel gauze with dry dressing daily until healed." On 05/08/13, a POS T.O. documented "Cleanse left inner buttock. Apply hydrogel gauze with foam dressing daily until healed..." On 05/20/13, a POS T.O. documented "D/C current treatment to left inner buttock. Cleanse area to left inner buttock with wound cleanser. Apply santyl to slough, cover with hydrogel gauze and dry dressing. Change daily and as needed (prn) until resolved." On 05/23/13, a POS documented "[MEDICATION NAME] to left inner buttock, change every 3 days until healed." On 05/23/13, a Nursing Home Note from Z1, Medical Doctor (MD), documented "He (R12) did develop an infected area to the lower sacrum. This opened up and drained and subsequently resolved. Now he has a small superficial ulcerated area there... recent infected sebaceous cyst of the lower sacrum. He will be having some pressure dressings to the lower sacrum until healed. We will continue to monitor." During a telephone interview conducted on 06/12/13 at 1:35 PM with Z1, R12's physician, it was determined that Z1 was notified via telephone by the facility "sometime in late April or early May, 2013" that R12 had an area on his lower sacrum that had become infected. Z1 stated that according to what the facility staff had told him, he said it sounded like an infected sebaceous gland. He ordered antibiotics and monitoring of the site. Z1 stated that he was notified sometime in early May, 2013 that the area had opened up and drained. Z1 stated that he had only seen R12's area on the bottom on 05/23/13. Z1 stated that the area he observed had decreased to a "pinpoint area on the sacrum." Z1 stated that he ordered another round of antibiotics and by 05/23/13 the infection had resolved. Z1 stated that he ordered a pressure relieving dressing until area had healed. Z1 further stated that he was not aware of an open area near the sacrum and cannot give a professional opinion of what it is or the cause. 4. On 6/6/2013 at 1:15pm R13 was sitting in the hall with head on chair and eyes closed. R13 stated she has a broken hip, and she had a pill. R13 rated her pain at 8, on a scale for pain severity of 0-10 with 10 being most severe. R13's Pain Management Flow Sheet dated 6/6/2013 at 9:00 am documented "No pain". There were no additional documentation for 6/6/2013. The PRN Medication sheet date 6/6/2013 at 11:40 am R13 was administered [MEDICATION NAME] 5-325 for complaints of Left lower extremity pain. At 1:00pm E19, LPN documented positive results. According to the facility Pain Prevention and Treatment #3 policy, " Pain assessment findings will be documented in the resident's medical record. this will include, but is not limited to the date, the rating, the treatment intervention and the resident response." 5. R5's Care Plan dated 5/13/2013, documented R5 is on hospice. The Care Plan does not document what role hospice has in R5's individualized care.