Every finding on record at Eden Vista Prospect Heights

Based on observation, interview, and record review the facility failed to ensure ongoing monitoring, assessment to identify worsening of skin impairment and notify the physician for appropriate treatment in a timely manner. This failure resulted in R11's Moisture Associated Skin Disorder (MASD) on left buttocks to progress to sacral/coccyx area stage 3 pressure ulcer with slough formation. This deficiency affects one (R11) of one resident in the sample of 9 reviewed for Wound Care Management. Findings include: On 12/9/25 at 11:36AM, Observed V15 CNA (Certified Nurse Assistant) and V16 CNA repositioned R11 to her left side for wound care. Observed open wound on sacrococcygeal area without dressing exposed to disposable adult brief soiled with urine. V16 said that she provided incontinence care to R11 this morning at around 7:00am and her wound dressing fell off. She forgot to inform the V17 RN (Registered Nurse) and V3 Assistant DON (ADON)/Wound Care Coordinator (WCC). V3 said that V16 CNA should notify her or the floor nurse this morning when R11's wound dressing fell off. The open wound should be covered to prevent infection and enhance healing. V3 provided wound care to R11. V3 said that R11's wound deteriorated from left buttocks MASD (Moisture Associated Skin Disorder) to pressure ulcer on sacrococcygeal area with 80% slough formation and 20% reddish tissue with serosanguinous drainage. V3 measured wound and obtained 1.5cm x 1cm x 0.1cm. V3 said that R11's wound worsens from last week when she saw her with V19 Wound Care Physician during wound rounds. V3 is not aware of this deterioration or worsening until today. V3 said that R11 wound treatment is being done by floor nurses, she only sees R11 during wound rounds as needed. V3 applied same treatment ordered for MASD, Zinc oxide and xeroform gauze covered with dry dressing. On 12/9/25 at 11:54AM, Surveyor asked V3 ADON/WCC if the treatment she applied for R11's deteriorated wound on sacrococcygeal is an appropriate treatment. V3 said that the treatment she applied is for MASD and is not appropriate treatment for open wound with slough formation. She said that she applied it for now until she received ordered from the physician.On 12/9/25 at 12:01PM, Informed V2 DON (Director of Nursing) of above concerns and requested for policies. On 12/9/25 at 1:17PM, Telephone interviewed with V18 RN (Registered Nurse). She said that she is the regular night shift nurse who took care of R11 on 10pm to 6am shift. She said that she provides treatment with zinc oxide cream and xeroform dressing on R11's left buttock MASD. The left buttock is dry, healed, skin intact and no open wound. She is not aware and did not see the pressure ulcer /open wound on sacrococcygeal area. She is aware that any skin changes or skin deterioration should be documented and notify the physician for appropriate treatment orders. On 12/9/25 at 2:05PM, V17 RN said that she is the regular morning shift (6am to 2pm) nurse who took care of R11 yesterday. She said that R11 has open wound in between her buttocks, sacrococcygeal area, with irregular wound edges, pinkish wound tissue, serosanguineous drainage, estimated quarter in size, it was from previous wound that re-open, but she cannot remember when. She has been applying zinc oxide, xeroform and covered with bordered dressing. On 12/9/25 at 3:05PM, Reviewed R11's medical records with V2 DON. R11 is admitted on [DATE] with diagnosis listed in part but not limited to History of falling, displaced Tri malleolar fracture of left lower leg, Closed fracture with routine healing, Subluxation of left ankle joint, Muscle weakness, Muscle wasting, Unsteadiness on feet and hearing loss. Active Physician order sheet indicated: Apply to Left buttocks Zinc oxide external paste 20% topically and xeroform then cover with dry dressing after cleaning with normal saline (NS) every shift and as needed for wound care (ordered 11/19/25). Apply to left buttocks Calcium alginate silver external pad 4x 8 topically after cleansing with NS one time a day, and every 8 hours as needed for wound care ordered 12/9/25 after surveyor observed the open wound/ pressure ulcer. Most recent Braden scale assessment for predicting pressure sore risk done on 11/3/25 indicated severe risk for skin impairment. Comprehensive care plan indicated: R11 has a pressure ulcer and has potential for further skin impairment related to fragile skin, impaired/limited mobility, and incontinence/exposure to moisture. Left buttocks MASD. Most recent wound assessment done by V19 Wound Care Physician on 12/3/25 indicated: Non pressure wound of the left buttocks partial thickness/ MASD, healing good, measures 1.58cm x 1.06cm x 0.1cm, light serous exudate open areas with exposed dermis. V3 WCC documented in R11's progress notes after surveyor wound observation indicated: Skin issues notes: During dressing change, R11 was observed with deteriorating left buttocks with increase surface to coccyx/sacral area. Informed V2 of concerns in wound care management to ensure ongoing monitoring assessment and coordination of care to identify worsening of skin impairment and notify the physician for appropriate treatment in a timely manner. The accurate identification of wound site so there is no confusion or discrepancy in wound treatment. Writing of treatment orders on the same site for different etiology. On 12/10/25 at 10:04AM, Observed R11's sacrococcygeal pressure ulcer with V2 DON and V3 ADON/WCC. V2 said that there is no skin impairment on left buttock. There is pressure ulcer with slough formation on left sacrococcygeal area. On 12/11/25 at 10:12AM, Telephone interview with V19 Wound Care Physician (WCP). He said that R11's MASD on left buttocks deteriorated to Stage 3 pressure ulcer on sacrococcygeal area. After wound debridement, 10% thick necrotic tissue, 20% sough and 70 granulation tissue. Reviewed V19 WCP wound report and informed of the discrepancy and inconsistency from observation made yesterday pertaining to the wound location. V19 said that he will update and send his report. V19 Wound Care Physician updated progress notes dated 12/10/25 for R11's wound report indicated: Wound originally at left buttock but has localized to sacral/coccyx area. Will change location to sacrum/coccyx. Facility's policy on Pressure Injury Prevention and Wound Care Management revised 8/25/25 indicated: Purpose: to provide health staff with the standards of care and processes to be followed for all residents: *To identify factors that places the residents at risks for the development of pressure injuries and to implement appropriate interventions to prevent the development of clinically avoidable wounds.*To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown.*To promote healing of existing pressure injuries and wounds.Policy: *It is the policy of this facility that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, in accordance with the comprehensive assessment and plan of care. * The facility will ensure that a resident who is admitted without a pressure injury does not develop a pressure injury, unless unavoidable*A resident who has pressure injury will receive care and services to promote healing and to prevent additional ulcers. Procedure:5. Resident's skin will be monitored daily during cares by nursing assistant and skin check will be completed weekly by licensed nurse. 6. Residents at risk for the development of pressure injury will have their individualized care interventions and approaches documented in the resident care plan.7. Skin impairmentsa. Weekly documentation will include pertinent characteristic of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues and description of any drainage, eschar, necrosis, odor, tunnelling, or undermining. 11. Daily, the clinicians responsible for caring for the resident will assess the status of dressing if present and evaluate for complications such as infection and or uncontrolled pain14. Wound and skin care interventions will be monitored and evaluated for effectiveness. Care plans will include specific and measurable goals and interventions. The care plan will be reviewed and revised at least quarterly or with significant change in condition. Prevention and Treatment Guidelines: 4. Wounds will be treated based on etiology of the wound.10. Nursing staff should update the attending physician immediately of wounds that have developed complications and or not healing as anticipated. Facility's policy on Physician orders revision date 11/13/24 indicated: Purpose: To provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards.

Based on observation, interview and record review the facility failed to provide timely oral care for one of three (R6) dependent residents reviewed for oral care in a sample of nine.Findings Include:On 12/9/2025 at 11:05am R6 was observed in bed with a foul mouth odor.On 12/9/2025 at 11:10am V16 (Certified Nursing Assistant-CNA) said I did oral care for R6 her mouth has an odor.On 12/9/2025 at 11:20am V2(Director of Nursing-DON), said I expect the nursing assistants to perform mouth care daily and as needed. An admission record dated 12/10/2025 indicates that R6 has an diagnosis of Hemiplegia and Hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side, dysphagia, oropharyngeal phase, GERD, and gastrostomy status, a order summary report dated 12/10/2025 that indicates NPO diet for failed speech swallowing dated 7/17/2023, a care plan dated 4/17/2024 with a focus of ADL self-care performance deficit impaired mobility, impaired cognition, hemiplegia left side a interventions for personal hygiene/oral care assist-one with grooming, oral hygiene-oral care every shift and often if needed.Facility Policy: Issue Date 3/15/2021 Activities of Daily Living (ADLs)Policy:Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable.Procedure.1. A resident will be given the appropriate treatment and services to maintain or improve is or her ability to carry out the activities of daily living.2. The facility will provide care and services for the following activities of daily living:3. Hygiene-bathing, dressing, grooming and oral care

Based on observation the facility failed to apply ace wrap bandage to resident's bilateral lower extremities for edema as ordered by physician. The facility also failed to develop plan of care in managing resident's edema. This deficiency affects one (R11) of one resident in the sample of 9 reviewed for Quality of care.Findings include: On 12/9/25 at 11:26AM, Observed R11 with swollen bilateral lower extremities with V17 RN (Registered Nurse). V17 assessed R11's bilateral lower extremities for pitting edema. V17 said that she has bilateral pitting edema but more prominent on left lower leg. R11 is alert and responsive with periods of confusion. She has impaired hearing and slurred speech. On 12/9/25 at 3:05PM, Reviewed R11's medical records with V2 DON (Director of Nursing). R11 is admitted on [DATE] with diagnosis listed in part but not limited to Essential hypertension, Atrial Fibrillation, History of falling, Muscle weakness, Muscle wasting, Unsteadiness on feet and hearing loss. Active Physician order sheet indicated: Apply ace wrap to bilateral lower extremities (BLL) two times a day for edema to BLL, apply in AM and remove in PM. Comprehensive care plan did not address managing of edema using ace wrap bandage. Informed V2 of above concerns. V2 said that they should be following physician order and address resident's BLL edema in care plan. Surveyor requested for policy in Edema management and Application of ace wrap bandage. On 12/10/25 at 11:44AM, V2 DON said that they don't have policy/procedure guidance in Edema management and application of ace wrap bandage to BLL for edema. Facility unable to provide policy and procedure in Edema management and application of ace wrap bandage to BLL for edema. Facility's policy on Physician orders revision date 11/13/24 indicated: Purpose: To provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards. Facility's policy on Care Plan Baseline and comprehensive revision date 7/18/24 indicated: Policy: The interdisciplinary team will develop an individualized, comprehensive care plan for each resident based on their medical condition, medical history, assessment from different members of the interdisciplinary team, lifestyle, and current resident goals.

Based on observation, interview, and record review the facility failed to follow physician order and implement care plan intervention for resident with limited mobility on left arm. This deficiency affects one (R3) of one resident in the sample of 9 reviewed for Limited mobility. Findings include: On 12/9/25 at 11:15AM, Observed R3 in Broda (Recliner chair) in the activity room leaning to right side off the recliner chair in front of V14 Activity Aide. No hand splint or wheelchair resting hand splint applied. Showed observation to V2 Director of Nursing (DON). V2 repositioned R3 in upright position. R3 is re-admitted on [DATE] with diagnosis listed in part but not limited to Senile degeneration of brain, Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, Abnormal posture. Active physician orders indicated Apply functional hand splint to left hand, may remove for hygiene, skin checks and as per patient's tolerance. Wheelchair arm through the left side to facilitate proper positioning in wheelchair while up in wheelchair every day and evening shift for left side weakness. Comprehensive care plan indicated: She has an ADLs self-care performance deficit related impaired mobility, generalized weakness, hemiplegia. Interventions: AFO on LLE while up. LUE sing and hand splint while up and during transfers, left elevate arm trough- observe skin with AM/PM cares for redness, rash, swelling, open areas, pain, or other skin problems. R11's MDS assessment dated [DATE] Section GG0115 Functional Range of motion coded 1 (impairment on one side) Upper extremity (Shoulder, elbow, wrist, hand) and 1 (impairment on one side) Lower extremity (Hip, knee, ankle, foot). R11's occupational therapy Discharge summary dated [DATE] indicated recommend assist with all ADLs and functional transfers, L arm trough, L resting hand splint. On 12/9/25 at 2:05PM, V17 RN (Registered Nurse) said that they did not apply R3's left hand splint and wheelchair resting arm.On 12/9/25 at 2:13PM, V11 Occupational Therapist (OT) said that they recommended left hand splint and left arm trough to prevent contractures due to limited mobility. On 12/9/25 at 3:05PM, Both V1 Administrator and V2 DON said that they don't have Restorative program. Informed of above concern regarding not following physician order and implementing care plan intervention of left-hand splint application and wheelchair arm trough. On 12/11/25 at 9:52AM, Both V1 Administrator and V2 DON said that they don't have policy to prevent contractures for resident who has limited mobility. Facility does not have policy on Restorative program.Facility's policy on Orthotics issued on 12/8/25 indicated: Purpose: To ensure safe, clinically appropriate, person centered use of hand splints and braces that support function, prevent/mitigate contracture, or deformity, protect healing tissues, and reduce pain while maintaining resident rights, dignity, and freedom from unnecessary restraints.Scope: This policy covers prefabricated and custom hand/wrist/finger orthoses (e.g., resting hand splint). It applies across all shifts and settings in the facility. Procedure: 1. Indications: *Prevention management of contractures or spasticity2. Orders:*A provider order is required for an orthotic device*OT/PT evaluation will include clinical rationale, fit, education plan and or monitoring scheduleFacility's policy on Physician orders revision date 11/13/24 indicated: Purpose: To provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards. Facility's policy on Care Plan Baselined and comprehensive revision date 7/18/24 indicated: Policy: The interdisciplinary team will develop an individualized, comprehensive care plan for each resident based on their medical condition, medical history, assessment from different members of the interdisciplinary team, lifestyle, and current resident goals.

Based on observation, interview, and record review the facility failed to implement fall prevention intervention to resident who has history of multiple falls. This deficiency affects one (R11) of one resident in the sample of 9 reviewed for Fall prevention program. Findings include: On 12/9/25 at 11:06AM, Observed R11 sitting in wheelchair in her room. She is alert with impaired hearing and slurred speech. The call light is away from her, unable to reach. Showed observation to V2 DON (Director of Nursing). V2 said that call light should be accessible and placed within resident reach for safety.On 12/9/25 at 3:05PM, Reviewed R11's medical records with V2 DON. R11 is admitted on [DATE] with diagnosis listed in part but not limited to History of falling, displaced Tri malleolar fracture of left lower leg, Closed fracture with routine healing, Subluxation of left ankle joint, Muscle weakness, Muscle wasting, Unsteadiness on feet and hearing loss. Care plan intervention indicated: Assist resident to meet needs and maintain safety; keep call light within reach, keep personal effects in easy reach. Comprehensive care plan indicated she is at risk for falls related to history of falls and weakness. R11's most recent fall assessment dated [DATE] indicated she is high risk for falling. R11's most recent unwitnessed fall dated 11/28/25 and witnessed fall on 11/26/25. Incident report on 11/26/25, indicated the nurse observed R11 sliding down from wheelchair She was lowered to the floor. R11 said that she was leaning forward to pick up the tissue. Root cause of fall completed. Incident report on 11/28/25 indicated R11 was found on the floor in her room. She said she did not know how she fell on the floor. She was sent to the hospital for evaluation. Root cause of fall completed just copy from the previous incident report dated 11/26/25. R11's Physician progress notes dated 12/8/25 listed in part but not limited to indicated: 2. Fall on 11/28/25 status post ER evaluation with no new injuries sustained: See plan as above. We will monitor patient closely. 5. Mechanical fall resulting in left ankle fracture/bimalleolar fracture: status post recent ortho follow up. PT and OT is ongoing.On 12/10/25 at 10:04AM, Observed R11 sitting in wheelchair in her room. She is alert with impaired hearing and slurred speech. The call light is again away from her, unable to reach. Showed observation to V2 DON (Director of Nursing). V2 said that call light should be accessible and placed within resident reach for safety. Facility's policy on Call light uses and response revision date 7/18/23 indicated: Purpose: 1. To respond promptly to resident's call for assistance.Procedure: 9. Be sure call lights are placed within reach at all times. Facility's policy on Care Plan Baselined and comprehensive revision date 7/18/24 indicated: Policy: The interdisciplinary team will develop an individualized, comprehensive care plan for each resident based on their medical condition, medical history, assessment from different members of the interdisciplinary team, lifestyle, and current resident goals. Facility's policy on Post fall revision date 10/13/23 indicated: Purpose: To ensure safe and appropriate care is provided to the resident after a fall has occurred. To implement new intervention to reduce the risk of further incidents. Root Cause Analysis and care plan:*Identify the underlying causes and risk factors of the fall*Current fall interventions will be reviewed for continued effectiveness. Care plan will be updated with new interventions based on the root cause of fall. *New intervention is monitored for effectiveness.Facility's policy on Fall Reduction revision date 10/13/23 indicated: Purpose:*To identify residents who are risk for falling and develop appropriate interventions to provide supervision and assistance devices to prevent or minimize fall related injuries. *To promote a systematic approach and monitoring process for the care of residents who have fallen and or those who are determined to be at risk. Procedure: Risk identification and assessment: 2. Each resident will be evaluated for risk for falls using the Morse Fall scale upon admission, readmission, upon a significant change of condition, quarterly and following each fall3. Residents with a Morse Fall Scale score greater that 45 should be considered at high risk for falling and a score ranging from 25-44 are at moderate risk for falling. Prevention and Treatment guidelines:1. Any risk factors identified by the Morse Fall Scale, MDS or other assessment should be reviewed and addressed as determined appropriate through the RAI (MDS) process including the resident's care plan.

Based on observation, interview and record review the facility failed to ensure pain was thoroughly assessed and adequately treated for teeth pain for one of three residents (R6) in a sample of nine reviewed for pain.Findings include:On 12/10/2025 at 11:00am R6 was observed in bed with dark areas, a foul odor to mouth and broken teeth with yellow to brown build up. R6 was asked did she have pain to her teeth R6 said pain.On 12/10/2025 at 11:25am V2(Director of Nursing-DON) said I expect all nurses to assess for pain, I did assess R6 for mouth pain and R6 did confirm that she was in pain which I administered acetaminophen 625mg two tabs and called the physician for an assessment for dental ASAP and notified the power of attorney-POA.An admission record dated 12/10/2025 indicates that R6 has an diagnosis of Hemiplegia and Hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side, dysphagia, oropharyngeal phase, GERD, and gastrostomy status, an order summary report dated 12/10/2025 that indicates NPO diet for failed speech swallowing dated 7/17/2023, a care plan dated 4/17/2024 with a focus of ADL self-care performance deficit impaired mobility, impaired cognition, hemiplegia left side a interventions for personal hygiene/oral care assist-one with grooming, oral hygiene-oral care every shift and often if needed. An order summary report dated 12/10/2025 for pain management evaluate every shift using numerical or visual analog pain scale every shift for pain management, an order dated 5/18/2023 for acetaminophen 325mg two tabs via feeding tube every six hours as needed for pain do not exceed 3000mg for 24 hours. A care-plan dated 4/23/2024 potential for pain for generalized discomfort, intervention to administer medication per medical doctor order for pain management.Facility Policy: Revision date 6/25/2018, 11/26/2019, 4/27/2022 Pain Management and AssessmentPolicy:The purpose of this policy is to develop a standardized method for assessing, monitoring, evaluating, managing, and documenting pain in both cognitively intact and impaired residents. Residents will receive necessary comfort, exercise greater independence, and enhance dignity through optimizing their ability to perform activities of daily living.Procedure:3.Assess and document pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms.a. staff will assess for pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.

Based on observation, interview and record review, the facility failed to ensure dental services were provided for a dependent resident for one of three residents (R6) reviewed for dental services in a sample of nine.Findings Include:On 12/9/2025 at 11:00am this writer observed R6 teeth very dark, broken in places, and a build up of yellowish film and foul odor.On 12/9/2025 at 11:20am this writer asks V2(Director of Nursing-DON) when was R6 last dental referral or exam.On 12/9/2025 at 11:25am V2 said I was unable to find a dental referral for R6, I did call the physician for a referral as soon as possible, I think because she is private pay, she has not had a dental exam she's been here for several years. An admission record dated 12/10/2025 indicates that R6 has an diagnosis of Hemiplegia and Hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side, dysphagia, oropharyngeal phase, GERD, and gastrostomy status, an order summary report dated 12/10/2025 that indicates NPO diet for failed speech swallowing dated 7/17/2023, a care plan dated 4/17/2024 with a focus of ADL self-care performance deficit impaired mobility, impaired cognition, hemiplegia left side a interventions for personal hygiene/oral care assist-one with grooming, oral hygiene-oral care every shift and often if needed. Facility Policy: Issue Date 1/6/2020 Oral Assessment and ManagementEvery resident will have a complete, accurate, and comprehensive assessment of oral status and needs consistent with residents' dental/oral status upon admission, with significant change or concerns noted, quarterly and annually.Procedure.1.Licensed nursing staff will complete an oral/dental review for every new resident.d. Inspect oral tissue and under dentures for presence of ulcers, masses oral lesions cavities, bleeding gums or loose teeth, soreness dried cracked lips, NPO pain or discomfort.2. Resident will be offered dental services upon admission and reviewed quarterly during care conferences.3. Dental/Oral concerns including but not limited to mouth pain, poor fitting dentures, pain/difficulty eating will ne addressed nursing and the provider updated with concerns.A. Facility will assist with making arrangements for dental services as ordered the provider.

Based on observation, interview, and record review the facility failed to perform hand hygiene after providing incontinence care and before handling clean disposable brief. This deficiency affects one (R11) of three residents in the sample 9 reviewed for Infection Control Program.Findings include: On 12/9/25 at 11:31AM, Observed V15 CNA (Certified Nurse Assistant) and V16 CNA repositioned R11 to her left side. Observed R11 soiled with urine. V15 removed the soiled disposable adult brief. She cleansed the perinium and sacral area with disposable cleansing wipes. V15 did not remove and perform hand hygiene. V15 took clean disposable adult brief and placed underneath R11. Informed V15, V16 and V3 ADON (Assistant Director for Nursing) of observation made regarding failure to perform hand hygiene after providing incontinence care and before handling clean adult brief. V3 said that V15 should perform hand hygiene after incontinence care and before handling clean brief. On 12/9/25 at 12:01PM, Informed V2 Director of Nursing (DON) of above observation and concern. Requested for hand hygiene policy. Facility's policy on hand Hygiene revision date 5/8/24 indicated: Purpose: To provide guidance to staff for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections. Washing Hands with Soap and Water1. Staff will perform hand hygiene by washing hands for at least 20 seconds with antimicrobial or non-antimicrobial soap and water should be performed under the following conditions: a. When hands are visible soiled with dirty or soiled with blood or other body substances:c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin:Using Alcohol-Based Hand Gel1. If the hands are not visibly soiled, used an alcohol-based hand rub for all the following situations: e. After handling items potentially contaminated with blood, body fluids or secretions.

Based on interview and record review, the facility failed to follow their pressure injury prevention and wound care management policy for one resident who was at moderate risk for skin breakdown by not implementing an air loss mattress, delay in evaluation by wound care doctor, failing to document skin assessments on admission/weekly, failure to obtain physician orders and document treatments. This affected one of three residents (R1) reviewed for wound care. Findings include: R1 was readmitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, anemia, gastrointestinal hemorrhage, hypertension, and heart disease. R13's Braden scale dated 2/13/25 documents moderate risk for skin breakdown. R1's admission screener dated 1/30/25 document under skin coccyx tiny skin opening. R1's progress note dated 1/31/25 documents: Readmit from skilled unit. Seen by V5 (MD),orders verified and noted. Skin check done. With skin discoloration [greenish ] in back of right hand, with brownish skin discoloration in left upper thigh. Scattered aged brownish spots on back. With redness in both heels, applied heel protectors. R1's progress note dated 2/7/25 documents: Noted two open skin in sacral area, measures #1 1.5 centimeters (cm) x 1 cm #2 1cm x1 cm. Also open skin on right hip 1 cm x 1 cm applied dry dressing and barrier cream to surrounding area. MD notified, refer to Home Health for wound care. R1's physician orders dated 2/7/25 created date 2/9/25 documents: Right buttock open skin cleanse with wound cleanser, pat dry, apply bacitracin then foam dressing twice a day until seen by home health. On 2/13/25 order hold transfer to skilled. R1's physician orders dated 2/7/25 created date 2/9/25 documents: Open skin sacrum cleanse with wound cleanser ,pat dry, apply bacitracin and cover with foam dressing twice a day until seen by home health. On 2/13/25 order hold transfer to skilled. There was no documentation of any home health visits from 2/7/25-2/13/25. R1's progress note dated 2/13/25 documents: Resident moved to skilled unit for rehab/ post hospitalization . Medications endorsed to nurse; verbal report given. R1's skilled progress notes do not document any admission note or completed skin assessment on 2/13/25. R1's medical record did not document any skin or wound assessment until 2/18/25. R1's wound evaluation dated 2/18/25 documents: pressure stage 3 to coccyx measuring length 2.57 centimeters (CM) x 0.96 cm width x 0.3 CM depth. Present on admission. R1's wound evaluation dated 2/19/25 documents MASD_ incontinence associated dermatitis to left gluteus measuring 3.66 CM length x 2.52CM width x 0.2 cm depth. Inhouse acquired. R1's physician orders do not document any wound or treatment orders when transferred to skilled unit on 2/13/25. R1's medication and treatment record do not document any treatments to R1 on 2/13/25 until 2/18/25. R1's physician order dated 2/18/25 with start date of 2/19/25. Coccyx cleanse with normal saline. Pat dry. Apply Medi honey and cover with bordered dressing every day. Discontinued 2/19/25. R1's physician order dated 2/14/25: Wound consult On 2/25/25 at 3:38PM, V2(DON) said skin assessment are done weekly by staff. On memory care if there was a wound reported it would be referred to home health for treatment. V2 said a referral was sent to home health but unsure what happened. V2 was requested to provide documentation of referral but none provided during the survey. V2 said home health did not evaluate R1's wounds and he was moved to skilled unit for treatment and therapy. V2 said staff should conduct a skin assessment when moving to another unit and was unable to find or locate any documentation of R1's skin assessment on 2/13/25. V2 said residents should have a treatment in place and documented in the medical record. V2 was unable to find, present or locate any documentation of treatment orders or administration of treatment for R1 from 2/13/25 through 2/18/25. V2 said R1 was expected to have an air loss mattress when he moved to skilled because of the wounds. V2 was unable to recall if he was provided an air loss mattress. On 2/26/25 at 9:35AM, V2(DON) said R1 was not seen by wound doctor on 2/14/25. V2 said regular wound doctor was not here and a replacement doctor was sent but did not see all the residents, including R1. On 2/26/25 253pm V6 (wound care MD) said he saw R1 on 2/19/25 for initial visit. V6 said he was unsure why R1 was not seen on 2/14/24. R1 was on group one mattress which is a pressure relieving mattress not an air loss mattress. V6 said he put in orders for air loss mattress after visiting due to wound being a stage three pressure sore. V6 said he would have expected some treatment to be in place for wounds to prevent infection prior to visit. V6 said staff can call him with any concerns or new wounds and does not recall any calls or concerns related to R1. On 2/26/25 at 1:03PM, V5(MD) said she would expect an order for any treatment for a open wound and all orders to be followed as ordered. Initial wound evaluation by V6(wound MD) dated 2/19/25 documents support surface group 1. Under wounds stage three pressure sore measuring 2.5 centimeters (CM) length x 3.5 CM width x 0.1cm depth. Under recommendations air loss mattress. Wound two moisture associated skin damage measuring 5.5 CM length x 4.5 CM width x o.1cm depth R1's mattress delivery order submitted 2/19/25 and delivered stat on 2/19/25. R1's physician order dated 2/18/25: may use air loss mattress. Please verify it's in good working condition. Facility pressure injury prevention and wound care management policy revised 3/4/24 documents: the purpose of the policy is to provide healthcare staff with the standards of care and the processes to be followed by all residents. To identify factors that places the resident at risk for development of pressure injuries and to implement appropriate interventions to prevent the development of clinically avoidable wounds, to promote systematic approach and monitoring process for the care of residents with existing wounds and those who are at risk for skin breakdown, to promote healing of existing pressure injuries and wounds. It is the policy of this facility that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing, with comprehensive assessment and plan of care. A resident who has a pressure injury will receive care and services to promote healing and to prevent additional ulcers. Skin impairments including pressure injuries should be assessed and documented weekly.

Based on interview and record review the facility failed to supervise and monitor a resident with identified to be an elopement risk, wandering behavior, and poor safety awareness from exitingh the facility without staff knowledge. This affected one of three residents (R1) reviewed for supervsion and elopement risk. This failure resulted in R1 exiting the facility via wheel chair through an exit door without staff knowledge. R1 was eventually found outside past the exit door on the ground after falling from the wheelchair. R1 was sent to the local hospital for evaluation Findings include: R1 face sheet denotes R1 has diagnosis of vascular dementia, unsteady on feet, history of falling, difficulty walking. R1 MDS dated 6.4.2023 section C denotes in-part attempt to conduct brief interview 0 is noted for No- resident rarely /never understood. Section C0700 denotes staff assessed R1 to have short term memory problems, and long-term memory problems. Cognitive skills for daily decision making- 2 are denoted for moderately impaired. 1 is denoted for yes there is evidence of acute change in mental status. One is denoted for inattention (behavior continuously present, does not fluctuate). One is denoted for disorganized thinking (behavior continuously present, does not fluctuate). Section E for behavior denotes Wandering- 3 (behavior of this type occurs daily). One is denoted that wandering places the resident at significant risk of getting to a potentially dangerous place (stairs, outside of facility). Two is denoted that R1 behavior has gotten worst compared to prior OBRA assessment. Facility final report to the department dated 7.6.23 denotes in-part, date of incident 7/4/ 2023 time of incident 2:40 PM. R1 name is listed. Location of incident immediately outside the exit door. Type of incident elopement and fall. Current resident diagnosis type 2 diabetes with diabetic chronic kidney disease, vascular dementia with other behavior disturbance generalized, arthritis and atherosclerotic heart disease. Description of incident initial report resident self-propelled self in wheelchair and pushed the exit door. Alarm sound. Staff responded and noted resident lying on sidewalk. Alert and oriented to self which is baseline. Sent to ER for evaluation. Final report to follow within 5 days. Final report 7/6/ 2023 resident returned to facility on the evening of 7/4/2023. All X-ray results perform in the ER were negative. Return from facility with orders to apply antibiotic ointment to facial abrasions. All exits on first floor were verified immediately to be functioning. In service conducted on elopement. Root cause of elopement seeking resident noted to be more anxious and agitated sense gradual dose reduction of antipsychotic medication. Order has been received to restart a low dose of Risperdal 0.25 milligrams at bedtime. Clinical team met and discussed with trust account representative the benefit of placing resident on the memory care unit and permission receive. Physician notified, family representative notified, sent to hospital, update residents' elopement and assess, update resident care plan to include interventions. R1 progress note dated 7.4.23 at 4:01pm completed by V6 denotes observed by staff RN and CNA lying prone on the ground with arms outstretched and head turned to the right with left cheek resting on the ground. On assessment, moderate amount of sanguineous drainage noted on the ground under left side of face. Resident left in place and 911 called while staff remained at side. Resident unable to describe event but denied pain. Vital signs as follows: BP 131/79, HR 90, RR 16, SPO2 97% on room air. Paramedics arrived and assessed resident before transferring to stretcher and transporting to ED for evaluation. PCP (primary care physician) notified. Attempts made to reach first and second emergency contacts without success. Unable to leave voicemail for either. Financial contact notified of change in condition and transfer to hospital. On 9.11.23 at 10:49am V12 (social worker) she completed R1 quarterly assessment dated 6.4.23 for section E-behavior. V12 said R1 has behaviors of wandering. V12 said she would not describe that R1 wandering getting worst but R1 started wandering into other resident's rooms. V12 said R1 is at risk for elopement. On 9.9.23 at 2:39pm V3 (certified Nursing Aide) she was in the room caring for a resident on her assignment, when she came out the room the heard the alarm and she went to the exit door (near room [ROOM NUMBER]) she opened the exit door and saw R1 laying on the ground. V3 said V1 came to the area right after her. V3 said she saw R1 laying on the ground. V3 said she did not do any vitals on R1. She did not move R1. V3 said she was not assigned to R1 and that V2 was assigned to R1 for that shift. V2 said she last saw R1 in the dining room around 2:30pm. V3 said R1 likes to wander, R1 likes to wander everywhere. On 9.11.23 at 8:59am V10 (Administrator) said she conducted the investigation for R1 elopement. V10 said she received a call at 2:48pm on 7.4.23 from V9 (Nurse) informing her that R1 had gone outside the exit door near the physical therapy room. V10 said she went to the scene and observed R1 laying on his stomach with his face to the side. V10 said the medics arrived quickly to take R1 to the hospital. V10 said she immediately began to check all the exit doors for proper functioning. V10 said all the doors that had alarms were working properly, and the door that had the electronic wandering device alarms were working properly. V10 said V3 (CNA), V7 (CNA), and V9 (Nurse) and V2 (CNA) was standing at the nurse's station when she interviewed them. V10 said V3 said she at standing at the nurse's station charting when she heard the alarm sound, V9 check the display screen verified the door that was alarming, V3 ran to the exit door near room [ROOM NUMBER] and V7 followed right behind her. V9 (Nurse) came right after. V10 said V3 was on the scene first. V10 said she could not get any information from V2. V10 said V2 was the assigned CNA to work with R1 for that shift. V10 said V2 told her that he was not working with R1 on 7.4.23 but V2 could tell her who he was working with on 7.4.23. On 9.9.23 at 12:50pm V6 (Director of Quality) said on 7.4.23 she had taken a break and when she returned inside the facility, she was informed that the alarms were going off on the skilled unit. V6 said she went to the skilled unit, to the exit door, she observed V9, V3, and a therapist outside with R1. V6 said R1 was laying on the ground in prone position with his face turned to the ground. V6 said she observed abrasion to R1 face and drainage. V6 said she assessed R1, and R1 was not responding appropriately to her satisfaction, V6 said R1 baseline was communicating few words at times. V6 said no one moved R1, V6 said V9 was sent to get the paperwork together while she stayed with R1. V6 said staff had already summons 911. V6 said V10 conducted the investigations and interviewed the staff. On 9.9.23 at 12:15pm V9 (Nurse) said she was the half nurse for 7/4/23. V9 said as the half nurse she would come in at 11:00am, she does the wound care, she does the admission paperwork, and she would pass the 12:00pm and 3:00pm medication to the residents on the high end of the unit. V9 said starting with room [ROOM NUMBER]. V9 said R1 was not assigned to her care, she just responded to the alarm. V9 said she did not get a report from V1 when she left for the day. V9 said she was not aware that V1 had left for an emergency. V9 said V3 arrived to R1 first, and she followed. V9 said R1 was observed laying on the ground kind of on his side with his face to the side. V9 said she did not move R1, 911 picked R1 up from the ground. V9 said R1 vital signs were assessed by V3. V9 said R1 wheelchair was there, not sure of location or position. R1 had a little blood on his face. V9 said she last saw R1 about 30 minutes prior to finding R1 on the ground outside. V9 said R1 is at risk for elopement. On 9.1.23 at 12:43pm V1 (Nurse) said she worked that morning on 7.4.23 on the skilled unit but had to leave early for an emergency at 10:40am. V1 timecard requested, facility failed to present V1 timecard during this survey. On 9.9.23 at 2:26pm V2 (Certified Nursing Aide) said R1 was not assigned to him. V2 said he do not know the last time he saw R1. V2 said he was coming out the trash room when V3 summons him to come to the area where R1 was laying. V2 then said he don't remember anything from that day. V2 said he don't remember what assignment he had. V2 said he don't remember who he was caring for when he had to dump the trash in the trash room. V2 said he don't know if it was a lady or man. V2 said he has been working for the facility for two years, and when he comes on duty he gets his assignment from the front desk, that how he knows where he's scheduled to work and what assignment he has. The facility assignment sheet was reviewed and V2 was informed that his name is listed to be assigned to R1. V2 continued to say he was not assigned to care for R1. V2 was asked if he was interviewed by the administrator during this investigation for R1 elopement, V2 continued to say he don't remember information from that day. V2 was asked did he care for R1 when R1 returned from the hospital on 7.4.23, V2 continued to say R1 was not assigned to R1, and he don't remember anything from that day. Facility assignment sheet dated 7.4.23 denotes that V2, V3, and V7 were the certified nursing aides assigned to work the skill care unit. V2 assignment was rooms 106-2 through 117. R1 room was assigned to V2. V2 timecard denotes V2 was on duty from 2:00pm until 12:00 midnight for the 7.4.23 evening shift. Using reasonable person concept, it is reasonable to believe R1 aide did not know he was assigned to R1's care, thereby not providing monitoring to R1 and knowing R1 whereabouts. On 9.9.23 at 11:35am V5 (Nurse) said she was not in the building when R1 eloped, V5 said when she pulled into the parking lot for her shift, she R1 on the ground and everybody standing around R1. On 9.9.23 during this survey tour with V8 (maintenance staff) it was observed that the exit door near room [ROOM NUMBER], opens to the outside. The exit door did not have a door alarm, the door did not have a 15 second delay when pushed open, the door opens immediately when pushed. The exit door did have an electronic wander device alarm system that activates when V8 cross the thrush hold with an electronic wander device in his hand. The sound did not emit at the door, the alarm sounds at the nurse station. Which is 98-100 feet away. Measured by V8 on 9.11.23. When exiting the door there is a concrete slab and then there a 3.5-inch step down to the sidewalk. R1 fall off the 3.5 in step on to the sidewalk in his wheelchair. On 9.11.23 at 11:30am V11 (scheduler) said V1 informed her manager that she will leave early on 7.4.23. V11 said V1 should have had a replacement. V11 said she was not aware that V1 was leaving early, V11 said she did not find a replacement for V1. V11 said the aides should know what resident assignments they have, and they should know where their residents are. On 9.11.23 at V4 (Director of Nursing) said she developed R1 plan of care for elopement on 7.5.23 when she returned to duty. V4 said R1 did not have a care plan in place for elopement on 7.4.23. V4 said R1 should have had a plan of care in place on 12.12.22 when R1 was identified to be at risk for elopement and the electronic wandering device was put in place. V4 said staff can round on R1 every two hours. R1 plan of care for safety reviewed with V4 denoting R1 should have frequent checks, and toilet as needed, if not sleeping keep him in common area. V4 said frequent checks means for the staff to see R1 every hour. V4 said the facility can not keep R1 in the common area/ dining room because he has a right to move around. V4 was asked what plan you had in place for R1 to ensure that he does not elope, V4 said frequent checks and keeping R1 in the common area. When asked if the interventions were effective if R1 was found outside on the ground, V4 said the interventions were not effective. V4 said she initiated R1 elopement care for R1 on 7.4.23. V4 said R1 has a history of wandering, and his wandering behaviors increased after his medication was changed recently. Review of R1 physician order sheet denotes R1 Risperdal 0.25 milligrams at bedtime was discontinued on 6.15.23. Request was made to review V1 and V9 timecards, several times during the survey, the facility failed to present the timecards during the survey. During this survey, surveyor could not establish what Nurse was assigned to R1's care when R1 was found outside on the ground on 7.4.23. Using a reasonable person concept, it is reasonable to believe R1 felt pain, sadness was scared when he fell to the ground after eloping from the facility on 7.4.23. R1 elopement assessment dated [DATE] denotes R1 is at risk for elopement, R1 has history of wandering off, getting lost etc. Patient at risk for elopement. Patient MD with order for electronic wander device placement. Facility policy titled Elopement with last revision date on 10/22 denotes in part it is the policy of this community to implement all possibles measures to protect/minimize any residents who attempts to elope. Elopement for purposes of this policy and procedures, is defined as a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary. This situation presents a risk to the resident health and safety. If a resident is found to be at risk for elopement, the resident care plan will include interventions for the prevention of elopement. The resident's picture will be located at stations or reception areas to alert staff of the possible risk elopement. Facility policy titled Accidents/falls with last revision date 10/2022 denotes in-part the facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. R1 plan of care with initiated date on 11/29/22, with intervention revision on 7.3.23 denotes in-part 7.2.23 frequent checks and toilet him (R1) as needed, if not sleeping keep him in common area. R1 plan of care for elopement shows initiated date of 7.5.23, after R1 eloped on 7.4.23. R1 elopement risk assessment dated 12.12.22 denotes R1 was an elopement risk and has a history of wandering off. R1 MDS dated ,d+[DATE] denotes R1 has behavior of worsening elopement. The facility did not develop an individualized plan of care for elopement for over 6 months.

Based on interview and record review the facility failed to follow the individualized plan of care for safety to ensure a resident remains in common area when awake. This affected one of three (R1) residents reviewed for implementation of care plan interventions. Findings include: R1 face sheet denotes R1 has diagnosis of vascular dementia, unsteady on feet, history of falling, difficulty walking. R1 MDS dated 6.4.2023 section C denotes in-part attempt to conduct brief interview 0 is noted for No- resident rarely /never understood. Section C0700 denotes staff assessed R1 to have short term memory problems, and long-term memory problems. Cognitive skills for daily decision making- 2 are denoted for moderately impaired. 1 is denoted for yes there is evidence of acute change in mental status. One is denoted for inattention (behavior continuously present, does not fluctuate). One is denoted for disorganized thinking (behavior continuously present, does not fluctuate). Section E for behavior denotes Wandering- 3 (behavior of this type occurs daily). One is denoted that wandering places the resident at significant risk of getting to a potentially dangerous place (stairs, outside of facility). Two is denoted that R1 behavior has gotten worst compared to prior OBRA assessment. Facility final report to the department dated 7.6.23 denotes in-part, date of incident 7/4/2023 time of incident 2:40 PM. R1 name is listed. Location of incident immediately outside the exit door. Type of incident elopement and fall. Current resident diagnosis type 2 diabetes with diabetic chronic kidney disease, vascular dementia with other behavior disturbance generalized, arthritis and atherosclerotic heart disease. Description of incident initial report resident self-propelled self in wheelchair and pushed the exit door. Alarm sound. Staff responded and noted resident lying on sidewalk. Alert and oriented to self which is baseline. Sent to ER for evaluation. Final report to follow within 5 days. Final report 7/6/ 2023 resident returned to facility on the evening of 7/4/2023. All X-ray results perform in the ER were negative. Return from facility with orders to apply antibiotic ointment to facial abrasions. All exits on first floor were verified immediately to be functioning. In service conducted on elopement. Root cause of elopement seeking resident noted to be more anxious and agitated sense gradual dose reduction of antipsychotic medication. Order has been received to restart a low dose of Risperdal 0.25 milligrams at bedtime. Clinical team met and discussed with trust account representative the benefit of placing resident on the memory care unit and permission receive. Physician notified, family representative notified, sent to hospital, update residents' elopement and assess, update resident care plan to include interventions. R1 plan of care with initiated date on 11/29/22 for safety/falls, with intervention revision on 7.3.23 denotes in-part 7.2.23 frequent checks and toilet him (R1) as needed, if not sleeping keep him in common area. On 9.9.23 at 12:15pm V9 said she last saw R1 in the dining room .5 hours prior to R1 being found outside on the ground. On 9.9.23 at 2:26pm V2 (CNA) R1 assigned CNA said he don't know where R1 was, he did not see R1 before R1 was found on the ground. V2 said R1 was not assigned to his care. On 9.11.23 at 9:50am V4 (Director of Nursing) said the facility cannot restrict the resident's movement. V4 was asked what interventions was in place to prevent R1 from leaving out the exit door. V4 replied the R1 had the wander guard. V4 was asked was it effective if R1 was able to leave out the facility. V4 said no. On 9.11.23 at 12:15pm V10 (administrator) said during her investigation V3 informed her that her (V3), V7, and V9 were all at the nurse station charting when the alarm sounded, the alarm displayed what door was alarmed. V3 went down the hall, V7 followed her to the exit door and V9 came behind them. During the facility tour the exit door was not observed in a common area, where R1 is care planned to be kept when he is awake. It is reasonable to believe that R1 left the common area went down hall, turned the corner, and went out the exit door, without staff being aware when they were at the nurse's station charting. Facility policy titled person centered plan of care last revision January 2023 denotes in-part Person centered care: integrated health care services delivered in a setting and manner that is responsive to the individual and their goals, values and preferences, in a system that empowers patients and providers to make effective care plans together.

Based on observation, interview, and record review, the facility failed to implement interventions according to resident's plan of care in preventing the development of a pressure ulcer for one (R13) of two residents in the sample of 21 reviewed for pressure ulcers. This failure resulted in R13's intact skin developing moisture associated skin damage on the left buttock which progressed to a Stage 4 pressure ulcer. Findings include: R13 is an [AGE] year-old female, admitted in the facility on 09/30/22 with diagnoses of Pressure Ulcer of Sacral, Stage 4, Neurocognitive Disorder with Lewy Bodies and Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. R13's POS (Physician Order Sheet) dated 04/14/23 recorded: Left buttock: Apply skin prep to surrounding skin. Cleanse with normal saline. Pat dry. Hypochlorous Acid Solution 0.05% and cover with gauze island with border dressing once daily one time a day for Stage 4 pressure wound of the left buttock. R13's Wound Notes documented the following: 08/19/22 - Non pressure wound of the Left Buttock full thickness Etiology: Moisture Associated Skin Damage (MASD) Wound size - 2.5 x 3.0 x 0.1 cm (centimeters) Recommendations: Return to bed after every meal to limit sitting time and facilitate wound healing. 10/06/22 - Unstageable (due to necrosis) of the left buttock full thickness Etiology: Pressure Wound size - 3.0 x 4.0 x not measurable cm. Wound progress: Deteriorated. Additional Wound Detail: Wound originally due to moisture associated skin damage. Deteriorated and found to have MRSA (Methicillin-resistant Staphylococcus aureus). Now Unstageable. Recommendation: Keep patient out of chair until wound improves. 11/18/22 - Stage 4 pressure wound of the left buttock full thickness Etiology: pressure Wound size - 3.0 x 3.3 x 2.0 cm. Recommendation: Keep patient out of chair until wound improves. On 05/15/23 at 11:00 AM, R13 was observed sitting in her wheelchair in the dining room. R13 is alert, verbal but unable to state if she has wound on the lower back when asked. She was observed in the dining room until 1:50 PM when she was put back into bed. At 4:50 PM until 6:00 PM, she was again observed up in her wheelchair in the dining room, eating dinner. On 05/17/23 at 12:49 PM, R13 was observed in the dining room sitting in her wheelchair. V8 (Certified Nurse Assistant/CNA) was asked regarding R13. V8 stated, I am her regular CNA. She has pressure ulcer on the left buttock and on the sacrum. She is usually up in the wheelchair at 7:30 AM until 10:00 AM, then to bed. She stayed in bed for two hours. She is up again at 11:30 AM for lunch and put to bed around 1-1:30 PM. This is her routine. She is wearing incontinent brief and uses the toilet. I check her for incontinence every two to two and a half. At 1:17 PM, R13 was brought to the bathroom by V8 for incontinence care. R13's incontinent brief was observed moderately soaked with urine. V8 stated that she changed her (R13) brief at 10 AM. V8 used disposable wipes to clean R13's peri area and buttocks then put on her brief. V8 did not apply any skin protective cream on R13's peri area and buttocks prior to securing her (R13) brief. Subsequently, she (R13) was transferred back to bed. On 05/17/23 at 1:25 PM, wound care was observed on R13 provided by V6 (Registered Nurse, RN). Her (R13) pressure ulcer on the left buttock is like the size of a dime, wound bed appeared red to purplish in color, with measurements of 1.4 cm x 2 cm x 1.3 cm. According to V6, She acquired her left buttock pressure ulcer in the facility on 08/19/22, started as MASD due to her being wet often. She needs to be checked and changed three to four times in the morning, like every two hours. Her MASD became Stage 4. Interventions in preventing pressure ulcer are repositioning; frequent toileting; wheelchair cushion; incontinence care every two hours. She should be sitting up for meals and put to bed after meals. On 05/17/23 at 9:48 AM, V3 (Acting Director of Nursing) was interviewed regarding R13 and pressure ulcer on the left buttock. V3 verbalized, She has a pressure ulcer on the left buttock, Stage 4, facility acquired, was identified on 08/19/2022, as non-pressure wound due to MASD. On 10/06/22, the left buttock MASD became Unstageable due to necrosis. On 11/18/22, the Unstageable left buttock pressure ulcer became Stage 4. It started as MASD caused by wet diaper or not applying moisture skin barrier. Staff has to check residents for incontinence care at least every two hours, more often. Change incontinent brief when needed. She always sits in the wheelchair, eats breakfast in the dining room, if she is on therapy, therapy takes her. She eats lunch in the dining room. She needs repositioning; offload wounds. V11 (Wound Doctor) was interviewed on 05/17/23 at 02:17 PM regarding R13. V11 stated, It was an acquired pressure ulcer on the left buttock, started as MASD, now its Stage 4. Cause is moisture from incontinence. In providing incontinence care, clean resident in a timely manner, follow whatever protocol in place, turn in a timely manner. Apply protective barrier cream which could be a part of incontinence care. Keep her out of chair since wound is improving. Weekly wound round documentation dated 05/11/23 recorded R13's left buttock Stage 4 pressure ulcer measures 1.5 x 1.3 x 1.4 cm, undermining/tunneling at 2.5 cm at 1 o'clock 5. Progression/Interventions: 6a. Additional information: Keep patient out of chair until wound improves; offload wound; turn side to side in bed every 1-2 hours if able. R13's care plan related to current medical/physical status. Pressure ulcer on sacrum on admission. 08/19/22 - pressure ulcer on left buttock Interventions/Tasks: Offload the buttocks, put her back to bed after meals on her sides as much as possible (02/06/23). Incontinence care with incontinent brief changes-apply skin protective cream to peri area and buttocks after toileting (02/06/23). Facility's policy titled Pressure Ulcer/Skin Integrity revision date 4/2022 documented in part but not limited to the following: Policy: Based on the comprehensive assessment of a resident, (name of group communities) will ensure: A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Based on observation, interview, and record review, the facility failed to follow their policy and procedures for fall prevention by not consistently assessing risks for falls, not ensuring fall interventions were implemented, not implementing effective fall interventions for residents experiencing multiple falls, and not providing adequate supervision for high risk fall residents who required increased supervision. This failure applied to two (R122 and R274) of four residents reviewed for falls and resulted in R274 sustaining a left femur fracture. Findings include: R274 is a [AGE] year-old male who originally admitted on [DATE] and currently resides in the facility. R274 has multiple diagnoses including but not limited to the following: left femur fracture, respiratory failure, CHF, COPD, need for assistance with personal care, unsteadiness on feet, difficulty in walking, and HTN. Per hospital discharge records dated 1/27/23, R274 was admitted to the skilled nursing side of the facility from assisted living due to weakness and gait abnormalities secondary to COVID-19 pneumonia. Per facility incident report dated 2/10/23 states in part but not limited to the following: Assisted living nurse reported that resident was found in front of his former room in assisted living lying on the floor. Writer immediately went to check on resident, noted resident lying on left side. Assisted to wheelchair with two staff. Asked resident what happened, I was trying to get my keys to open the door and I lost my balance. Noted skin tear on left knee and verbalized pain on the left hip. Resident sent out to hospital with the paramedics. Mobility: ambulatory with assistance. Summarize the post-fall findings: Resident lost his balance while opening his assisted living room. Left the skilled unit without notifying staff. New fall prevention interventions to be implemented as a result of the assessment: notify staff if needing to leave the unit. Per hospital records with admitted [DATE] show R274 was admitted with a left hip fracture. On 5/15/23 at 10:15AM, it was observed that R274's room is down the hall, multiple rooms away from the nursing station. On 05/17/23 at 10:23AM, V6 (Registered Nurse/RN) was interviewed regarding R274's functional status and care. V6 said R274 was a previous resident of our assisted living side and came here for therapy. R274 is currently in a wheelchair and can move independently in his wheelchair. He needs assistance with ambulating and transferring because he is unsteady. He does attempt to get up unassisted especially when he needs to go to the bathroom. We try and keep him in a common area because he needs increased supervision. He has periods of confusion, and sometimes he's hard to understand. It is to be noted that R274 had a fall on 4/12/23 and 4/28/23 in his room. At 2:59PM, V3 (Director of Nursing/DON) was interviewed regarding R274 fall on 2/10/23. V3 said R274 ambulated with his walker to his old apartment on the assisted living side of the facility. The nurse covering the assisted living side found him on the floor outside of his old apartment. He walked off the unit without informing anyone or anyone noticing him. R274 is confused and forgetful and did need increased supervision at the time of his fall. The intervention put in place at this time was for R274 to notify the staff when leaving the unit. Attempted to interview V19 (former employee) and V20 (Certified Nursing Assistant/CNA) on multiple occasions but was unable to get a hold of during course of survey. R274's care plan with initiation date of 1/27/23 states, in part but not limited to the following: Focus: Actual/at risk/ and/or potential for complications with or falls r/t current medical/physical status. Has medications/diagnoses that can affect fall risk. Patient with unsteady gait. Goals: Will be free of serious injuries r/t falls through next review date. Will have reduced risk for falls with stated interventions through next review date. Interventions: Frequent checks and toilet him if needed, encourage fluids, encourage him to stay in common area if not sleeping date initiated 4/28/23. Check for unmet needs: pain, toileting, hunger, thirst, temperature- date initiated 2/10/23. Reinforce need to use call light to request assistance- date initiated 2/10/23. Frequent checks in the afternoon, offer different seating positions, encourage fluid intake during all interactions- date initiated 4/13/23. R274 MDS (Minimum Data Set) dated 2/10/23 states, in part but not limited to the following: Staff assessment for mental status: short term memory indicated a memory problem. Activities of daily living assistance: limited assistance with transferring and walking in corridor. Facility policy titled Accidents/Falls with revision date of 10/2022 states, in part but not limited to the following: Policy: the facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. Procedure: 3. An immediate/initial care plan for fall risk will be developed for any newly admitted residents whose assessment indicated that the resident was at risk for falls/accidents. This plan of care is communicated to all appropriate staff. 5. Resident care plans should be evaluated and updated with each fall with a new and applicable intervention based on root cause. The focus is to be on prevention and maintaining a safe environment. 7. Any episode of a fall should be documented within the electronic health record within risk management/incidents. Each incident/accident or fall must be investigated and/or assessed to determine the root cause of the episode to prevent any further injury. The interdisciplinary team will review all incident/accident. 9. A post fall assessment will be conducted following any fall episode. 40718 R122 is an [AGE] year-old female with diagnoses history including Dementia, Alzheimer's, Restlessness and Agitation, Bipolar Disorder, Anxiety Disorder, Difficulty in Walking, Unsteadiness on Feet, Need for Assistance with Personal Care, and Chronic Congestive Heart Failure who was admitted to the facility 03/16/23. On 05/15/23 from 10:55 AM - 11:02 AM, observed R122 lying in her bed in her room with no clothes or socks on attempting multiple times to get out of bed. R122 stated, Can I get out of here? Observed there were no staff in or near R122's room. On 05/15/23 at 12:24 PM, observed R122 was placed next to the nurse's station in her wheelchair and given an activity book. Observed R122 appeared agitated and sat book down on a chair next to her. Observed R122 was not engaged in activities with staff or residents. V6 (Registered Nurse/RN) stated R122 is a high fall risk. On 05/15/23 at 02:26 PM, V17 (Family Member) stated she received a call from the facility today notifying her that R122 had fallen by the nurse's station earlier in the morning and then received another call later that she had rolled out of bed. V17 stated unfortunately, R122 does fall often. R122's progress note dated 3/26/2023 10:00 AM documents she was observed sitting on the floor near her bed. Initial Abuse Reportable reviewed 05/16/23 documents on 03/28/23 at approximately 2:30 PM R122 was reported to have a fall and her left-hand fingers showed signs of swelling. R122's progress note dated 3/29/2023 3:27 PM documents R122's left middle finger is swollen, discolored and immobile. Physician was notified. R122's progress note dated 3/31/2023 9:54 AM documents writer went to check on R122, and she was observed on the floor on her knees in a crawling position in her room. R122 was wet and wanted to go to the bathroom. R122 has full range of motion in her lower extremities but complains of pain to her left leg. R122 does not remember how she fell . R122's progress note dated 4/3/2023 3:45 AM documents she became restless, screaming for her family, and trying to get up by herself, attempted to calm her down but was unsuccessful. Placed R122 on close watch, she is a high risk for fall. R122's progress note dated 4/4/2023 6:23 PM documents a Certified Nursing Assistant passed by R122's room and saw her on the floor. Writer went to check, noted resident sitting on the floor, wearing nonskid socks, with her wheelchair behind her. Asked R122 what happened, per R122 I don't know. R122's progress note dated 4/4/2023 06:19 AM documents she had episodes of on and off screaming, attempted to get up, able to redirect. Continuous monitoring done. R122's fall risk assessment dated [DATE] documents she has impaired mobility, severely impaired cognition, poor safety awareness, is becoming restless and increased anxiety always attempting to get up from chair or roll out of bed; Requires one-on-one sitter. R122's progress note dated 5/15/2023 3:18 PM documents she was noted to be on the ground by writer, Certified Nursing Assistant and two therapists. The facility's fall log from 11/15/22 to 05/15/23 documents R122 had 15 unwitnessed falls from 03/28/23 - 05/15/23. There were no post fall/fall risk assessments completed for R122's falls occurring 03/26/23, 03/28/23, 03/31/23, 04/05/23, and 04/08/23. R122's medical records did not include progress notes or incident reports for 10 of her falls. The facility could not provide incident reports for 14 of her falls. R122's current care plan initiated 03/16/23 documents she is at risk for falls and/or has the potential for complications with or falls related to current medical/physical status. R122 has medications and diagnoses that can/may affect fall risk. R122 fell [DATE], 3/31/2023, 3/28/2023, 4/2/2023, 4/4/2023, 4/7/2023,5/13/2023, and 5/15/2023 with interventions including - frequent checks (initiated 03/28/23); toilet her after lunch and dinner, encourage her to stay in common area if not sleeping, Involve her in activities (initiated 5/15/2023); Provide individualized AM activities (initiated 4/10/2023); Check for unmet needs: pain, toileting, hunger, thirst, temperature (initiated 3/29/2023); Continue frequent checks, toilet before meals, Put resident close to nurses station/common area, nonskid socks, Keep in common before meals area when awake (initiated 3/31/23, revised 4/07/23). R122's fall care plan did not include any initiated or revised interventions for falls occurring 03/26/23, 04/02/23, 04/04/23, 04/05/23, 04/06/23, 04/08/23, 05/10/23, or 05/13/23. On 05/17/23 at 11:09 AM, V3 (Director of Nursing/DON) stated floor nurses complete incident reports and post-fall reviews. V3 usually stated the next day in the clinical meeting the Director of Nursing and the clinical [NAME] review these reports, and a new intervention is implemented and added to the care plan. On 05/17/23 at 01:22 PM, V3 (DON) stated if post fall reports are not completed, it could prevent care plan interventions from being implemented. V3 agreed if post-fall assessments are not completed, this may prevent identification of potential contributing factors of falls. On 05/17/23 at 03:07 PM, V3 (DON) she was informed by V18 (Registered Nurse/RN) that R122 needs constant supervision, and if you turn your head from her for even a moment she'll fall. V3 stated R122 requires constant monitoring while in her room. V3 stated she doesn't believe the facility can provide one-on-one care for R122 unless there is an emergency or under certain circumstances. V3 stated R122's room is not necessarily close to the nurse's station but somewhat close. V3 stated R122 was closer to the nurse's station. V3 stated a room close to the nurse's station would be close enough to the nurse's station so that you can respond within seconds if an issue arises. V3 stated if R122 does move around, her room is not close enough to the nurse's station for staff to respond in seconds. V3 stated the facility does not currently use any devices to detect a resident's movement. V3 stated R122 has a habit of trying to get out of her bed. V3 stated when R122 is awake, she is in the common area.

Based on observation, interview, and record review, the facility failed to follow their policy and procedures for preparing and storing food under sanitary conditions by not ensuring food was stored to prevent contamination, not ensuring all dishware, food storage containers, and kitchen equipment were properly cleaned, not ensuring kitchen employees and facility staff practiced appropriate hygiene in the kitchen area, and not performing safe food thawing practices. This failure has the potential to affect all 18 residents who currently reside in the facility and receive food from the kitchen. Findings include: On 05/15/23 from 09:50 AM - 10:05AM, observed a whole turkey thawing in a sink under sitting water. V12 (Dietary Manager) stated the turkey should be thawed under running water. Observed ice machine scoop stored in the ice machine in contact with ice. V12 stated the ice machine originally came with an internal storage piece for the scoop, however, the scoop is usually stored outside the ice machine in a holder. Observed V12 and V13 (Cook/Mentor) with their hairnets not completely covering their hair and a significant portion of their hair exposed on the sides and back of their heads while walking through and working in the kitchen. Observed lid of storage bin containing breadcrumbs partially open. V12 stated the breadcrumbs are not used much. V12 stated the storage bin should be completely closed. Observed the storage bins containing thickener, sugar, and breadcrumbs to be covered in dust and soiled with some food spillage. V12 stated the storage bins need to be free of dust and food particles to prevent contamination. On 05/16/23 from 11:36 AM - 12:00 PM, observed V12 (Dietary Manager) and V13 (Cook/Mentor) with their hairnets not completely covering their hair and a significant portion of their hair exposed on the sides and back of their heads while walking through and working in the kitchen. Observed V14 (Cook) with a large portion of hair exposed from the sides and back of her hairnet while preparing meal trays in the kitchen. Observed V15 (Cook) with hair exposed from the sides and back of his hairnet while prepping food in the kitchen. V12 stated if hair falls in food, it will be contaminated. V12 asked how should hairnets be worn in the kitchen and what about eyebrows? Observed a large rack full of cleaned dishes with heavy dust build up on all racks, observed multiple cleaned dishes with particles and substances on the surface. V12 confirmed the cleaned dishes were not free of particles and substances. V12 stated the dish racks are cleaned every other week. V12 stated if the dish racks are not free of dust or substances, they could contaminate the cleaned dishes. Observed V16 (Receptionist) enter the kitchen without donning a hairnet or performing hand hygiene, grab a bowl from the kitchen, and then leave. On 05/16/23 at 12:05 PM, V16 (Receptionist) stated she entered the kitchen to get a bowl for herself and asked if she needed to don a hairnet or perform hand hygiene if she only enters the kitchen to get a bowl for herself. Per facility matrix dated 05/15/23, current census is 18 residents. The facility's Employee Sanitary Practices Policy reviewed 05/18/23 states: Wear hair restraints (hairnet, hat) to prevent hair from contacting exposed food. The facility's Personal Hygiene and Health Reporting Policy reviewed 05/18/23 states: Hair restraints must be worn around exposed foods, in the kitchen or food service areas. The facility's Cleaning Dishes/Dish Machine Policy reviewed 05/18/23 states: All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The facility's Handling Clean Equipment and Utensils Policy reviewed 05/18/23 states: Clean equipment and utensils will be stored in a clean, dry location in a way that protects them from splashes, dust, or other contamination. Stationary equipment will also be protected from contamination. The facility's Food Storage Policy reviewed 05/18/23 states: Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored by methods designed to prevent contamination. Plastic containers with tight-fitting covers must be used for storing grain products, sugar, and broken lots of bulk foods. The facility's General Food Preparation and Handling Policy reviewed 05/18/23 states: The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. Meats and poultry will be defrosted using safe thawing practices: In the sink submerging the item under cold water that is running fast enough to agitate and float off loose ice particles. The facility's Food Safety: Ice Policy reviewed 05/18/23 states: Ice scoop will not be stored in the ice machine unless a scoop holder is installed in the machine by the manufacturer. The facility's Production, Storage and Dispensing of Ice Policy reviewed 05/18/23 states: Ice scoops will be stored outside of the ice dispenser in a closed, clean container or in the ice machine in the scoop storage container provided by the manufacturer.

Based on observation, interview, and record review, the facility failed to ensure that multidose vials and insulin pens are labeled with dates opened; and discontinued medications are disposed of per policy. This failure affected two (R2 and R122) of two residents reviewed for medication storage and labeling. Findings include: Per facility matrix dated [DATE], current census is 18 residents. On [DATE] at 10:36 AM during inspection of medication room and medication carts, the following were observed: Three multidose vials of Tubersol, opened and undated as to its first use were observed stored in the refrigerator in the medication room. V6 (Registered Nurse, RN) was asked if the vials should be dated when opened. V6 stated, We're supposed to label it with date opened, expiry date and our initials. Inside medication cart number 2, R2's and R122's Insulin Glargine pens were observed opened and used but not dated. V6 verbalized, We have to date the insulin pens when opened, because it is only good for 30 days from the date it was opened. V3 (Acting Director of Nursing) was interviewed on [DATE] at 01:09 PM regarding medications labeling. V3 replied, When we open medications, we put the date opening and store according to the instructions on the bottle or bingo card on where to keep it when opened. Tubersol multidose vials need to be dated when we opened it because after four weeks, we have to discard it. For Insulin pens, we also have to date it when first used because it is good for 28 days. On [DATE] at 2:55 PM, V4 (Pharmacist) was also interviewed regarding labeling of Tubersol and Insulin pens. V4 verbalized, Tubersol multidose vials - when opened, it should be dated because it is only good for 30 days when opened. We have to date insulin pens when opened because it is only good for 28 days. Tubersol Purified Protein Derivative Package Insert documented the following in part: Storage A vial of Tubersol which has been entered and in use for 30 days should be discarded. Do not use after expiration date. Insulin Glargine Package Insert documented the following in part: 16.2 Storage Storage conditions are summarized in the following table: 3ml (milliliter) single-patient-use prefilled pen: In use (opened) - 28 days (room temperature only). Facility's policy titled Medications Labeling and Storage revision date ,d+[DATE] stated in part but not limited to the following: Procedure: 2. Label includes the resident's name, drug name, dose, frequency, route instructions for us, and expiration date. R122's Insulin Glargine was discontinued on [DATE] according to POS (Physician Order Sheet) but was still stored in the cart. Facility's Pharmacy Policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals revision date [DATE] documented in part but not limited to the following: Procedure: 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. 5.1 Facility staff may record the calculated expiration date based on date opened on the primary medication container. 5.3 If a multi dose via of an injectable medication has been opened or accessed (e.g. example, needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specified a different (shorter or longer) date for that opened vial. 16. Facility should destroy or return all discontinued, outdated/expired or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other Applicable Law, and in accordance with policy 8.2 (Disposal/Destruction of Expired or Discontinued Medication).

Based on observation, interview, and record review, the facility failed to follow their policy and procedures for fall prevention by not comprehensively assessing risks for all falls and not ensuring fall interventions were implemented for a resident who is at high risk of falls. This failure applied to one (R122) of four residents reviewed for falls. Findings include: R122 is an [AGE] year-old female with diagnoses history including Dementia, Alzheimer's, Restlessness and Agitation, Bipolar Disorder, Anxiety Disorder, Difficulty in Walking, Unsteadiness on Feet, Need for Assistance with Personal Care, and Chronic Congestive Heart Failure who was admitted to the facility 03/16/23. The facility's fall log from 11/15/22 to 05/15/23 documents R122 had 15 unwitnessed falls from 03/28/23 - 05/15/23. There were no post fall/fall risk assessments completed for R122's falls occurring 03/26/23, 03/28/23, 03/31/23, 04/05/23, and 04/08/23. R122's medical records did not include progress notes or incident reports for 10 of her falls. The facility could not provide incident reports for 14 of her falls. R122's current care plan initiated 03/16/23 documents she is at risk for falls and/or has the potential for complications with or falls related to current medical/physical status. R122 has medications and diagnoses that can/may affect fall risk. R122 fell [DATE], 3/31/2023, 3/28/2023, 4/2/2023, 4/4/2023, 4/7/2023,5/13/2023, and 5/15/2023 with interventions including - frequent checks (initiated 03/28/23); toilet her after lunch and dinner, encourage her to stay in common area if not sleeping, Involve her in activities (initiated 5/15/2023); Provide individualized AM activities (initiated 4/10/2023); Check for unmet needs: pain, toileting, hunger, thirst, temperature (initiated 3/29/2023); Continue frequent checks, toilet before meals, Put resident close to nurses station/common area, nonskid socks, Keep in common before meals area when awake (initiated 3/31/23, revised 4/07/23). R122's fall care plan did not include any initiated or revised interventions for falls occurring 03/26/23, 04/02/23, 04/04/23, 04/05/23, 04/06/23, 04/08/23, 05/10/23, or 05/13/23. On 05/17/23 at 11:09 AM, V3 (Director of Nursing/DON) stated floor nurses complete incident reports and post fall reviews. V3 stated usually the next day in the clinical meeting the Director of Nursing and the clinical [NAME] review these reports and a new intervention is implemented and added to the care plan. On 05/17/23 at 01:22 PM, V3 (DON) stated if post fall reports are not completed, it could prevent care plan interventions from being implemented. V3 agreed if post fall assessments are not completed this may prevent identification of potential contributing factors of falls. The facility's Accidents/Falls Policy reviewed 05/18/23 states: Resident care plans should be evaluated and updated with each fall with a new applicable intervention based on root cause. The focus is prevention and maintaining a safe environment. Any episode of a fall should be documented within the electronic health record within risk management/incidents. Each incident/accident or fall must be investigated and/or assessed to determine the root cause of the episode to prevent any further injury. The interdisciplinary team will review all incident/accident A post fall assessment will be conducted following any fall episode.

Based on interview and record review, the facility failed to only use one incontinent brief at a time and failed to provide incontinence care in a timely manner for one of three residents (R1) reviewed for bowel and bladder in the sample of three. Findings include: The facility's Certified Nursing Assistant (CNA) Job Description, dated 2017, documents the position is responsible for providing assigned residents with routine daily nursing care. This same policy states, Key Position Specific Roles and Responsibilities: Ensure that residents and families receive the highest quality of service in a caring, compassionate and dignified manner which recognizes the individual's needs and rights. Assists residents with Activities of Daily Living (ADL) in a manner conducive to their safety and comfort. Ensure that residents are clean, neatly dressed and well-groomed. The facility's Activities of Daily Living-ADL policy, dated May 2020, documents elimination, hygiene, mobility and dining as ADLs. This same policy states, A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene. The facility's Bowel and Bladder Management policy, dated May 2020, states, There is a system to ensure that each resident with bowel or bladder incontinence will receive appropriate treatment and services to achieve or maintain as much normal elimination function as possible. Procedure: 4. Residents who are unable to participate in a toilet schedule program or do not respond to toileting trial will receive individualized supportive management (e.g. check and change schedule). 6. The comprehensive person-centered care plan will be updated/revised to include the resident's bowel and bladder needs, goals, and personal preferences. The Resident Council Minutes, dated 11/30/22, states, Staff has been cut to two caregivers, not giving enough time to give residents the proper attention that is needed. It is not the amount; we need the quality of care because it is not fair. Quality of care and time is very important and we are not getting it. The Resident Council Minutes, dated 10/28/22, documents waiting period for the bathroom is too long and documents a request for more caregivers. The Resident Council Minutes, dated 9/29/22, documents longer than usual call light response times. R1's Face sheet documents R1 with an initial admitted [DATE] and a current admitted [DATE]. R1's Order Summary Report documents R1 with diagnoses to include but not limited to: Need for Assistance With Personal Care; Morbid Obesity; Parkinson's Disease; Osteoarthritis; Chronic Pain Syndrome; Other Abnormalities of Gait and Mobility; Unsteadiness on Feet; and Localized Edema. This same report documents an order for Lasix (Diuretic) 40 milligram tablet by mouth one time a day for increased edema. R1's Minimum Data Set (MDS) Assessment on 10/14/22 documents the following: R1 is cognitively intact; R1 requires extensive assistance of two-person physical assistance for toileting; A toileting program had not been attempted since R1's admission, entry or reentry to the facility or since R1's urinary incontinence was noted; and R1 is always incontinent of bowel and bladder. R1's Care Plan documents R1 requires assistance with incontinence care and incontinent brief changes and is non-ambulatory in a wheelchair. R1's Pressure Ulcer Risk Assessment Tool, dated 4/10/22, documents R1 has impaired mobility due to weakness and chronic pain and R1 has difficulty standing up and requires two persons to transfer and reposition in bed. R1's Bladder Data Collection Tool, dated 10/1/22, documents R1 is incontinent of bladder and documents clothes or incontinence product wet as a sign and symptom of urinary incontinence. The facility's report to the local state agency documents on 11/4/22 at 4:30 PM, V5 (R1's Family Member) had concerns after visiting R1 at the facility. This report states, V1(Administrator) spoke with V5. V5 alleged that when V5 came in to visit R1 that R1 was wet to the point that it was soaking into R1's shorts. V5 also reported that R1 was double diapered, and urine had dripped on the floor as well. V5 also reported that she asked V4(Certified Nursing Assistant/CNA) on duty to help R1 and V4 came and gave incontinence care. V5 requested that accused CNA (V3) not be assigned to R1 in the future. Investigation began and accused CNA (V3) was suspended pending the investigation. During the interview, V3 stated that she did not double diaper R1 but used another (incontinence brief) as an additional layer. V3 explained that V3 tore the disposable brief apart and only used the center part as a liner and did not use two briefs as in one on top of the other. Afternoon CNA on duty V4 was interviewed regarding the double (incontinence brief). V4 stated that when V4 changed R1, there was no double (incontinence brief) as in one on top of the other. V4 stated that there was an extra layer pad inside the disposable brief. V4 added that R1 urinates a lot. This report documents that R1 stated he was double diapered and that his CNA (V3) only took him to the restroom once. V2's (Director of Nursing/DON) written statement dated 11/7/22 documents that on 11/4/22 at 6:05 PM, V2 received a call from V6 (Registered Nurse/RN) regarding concerns from V5. V5 told V2 that R1 was double diapered and soaked full of urine. V3 told V2 that V3 used the middle part of the disposable brief as an extra layer of protection to prevent leakage. On 12/4/22 at 12:02 PM, V5 (R1's Family Member) stated that around 4:30 PM on 11/4/22, V5 came to visit R1 at the facility. V5 stated, R1 was a little off. I visit every day, and something didn't seem right with R1. I asked R1 to tell me what was wrong, and he had stated that he had not been changed since early that morning. I could then see that R1's (incontinent brief) was bulging out of the bottom of his shorts and there was a puddle of urine on the floor under his wheelchair. I had to use four paper towels from the bathroom to clean up the puddle of urine under his chair. I don't know how else to describe it other than his brief looked like a baby at a swimming pool. (The incontinence brief) was full to capacity and bulging out of (R1's) shorts. (R1) had told me that (V3) had been using two (incontinence briefs) for about a week. On 12/4/22 at 11:22 AM, V4 (CNA) stated that on 11/4/22 around 4:30 PM, V5 had come up to V4 and asked if V4 could change R1. V4 stated that V4 was not assigned to R1 but V4 could see that V5 was upset so V4 changed R1's incontinence brief. V4 verified seeing a ripped piece of the incontinence brief inside the main incontinence brief used as an extra. V4 stated that R1 urinates a lot. V4 stated that R1 was alert and oriented and sometimes would call to be changed and other times would not. On 12/4/22 at 11:50 AM, V2 (Director of Nursing/DON) stated that on 11/4/22, V6 had called V2 because V5 had some concerns. V2 stated that V2 called V5 and that V5 expressed concerns that R1 was double diapered, not changed and that urine had leaked onto the floor. V2 stated that an investigation was started right away. V2 stated that V3 (CNA) had told V2 that V3 was using the center of an incontinence brief as an extra layer of protection for R1. V2 stated that V3 should not have ripped a brief and placed it inside the other one and that and only one disposable incontinent brief should be used at a time. The Daily Assignment Sheet for 11/4/22 documents V4 (CNA) and V8 (Certified Nursing Assistant/CNA) were the only CNAs for the skilled unit at 2:00 PM and documents that V7 (Certified Nursing Assistant/CNA) came in early at 6:11 PM. On 12/5/22 at 12:09 PM, V2 stated that the CNAs should do rounds on the residents constantly and stated that V4 was covering extra residents until another CNA arrived. On 12/5/22 at 11:57 AM, V3 (CNA) stated that on 11/4/22, V3 worked 6:00 AM-2:00 PM. V3 stated that V3 has only worked at the facility for approximately three months and that when V3 started, V3 was trained to use a ripped piece of an incontinent brief for R1 as an extra guard. V3 stated, I was told R1 was very incontinent. I pushed R1 into (R1's) from after lunch from the dining room. R1 was dry at that time. The other CNA coming in at 2:00 PM was late. We are always working short. I don't know when the next shift checked on R1 again after I left.

Based on interview and record review, the facility failed to prevent an incident of staff to resident physical/mental abuse while conducting activities of daily living. This failure affected 1 of 3 residents (R1) reviewed for abuse. This failure resulted in R1 being thrown to bed/pushed to the bed, having linen thrown on top of R1 and then handled roughly again being pushed side to side on the bed. Findings include: On 11/10/22 at 11:15am, R1 stated that R1 told V5 agency CNA (Certified Nurse Aide) that staff always use a mechanical lift device to transfer R1 into bed. R1 stated that V5 would not listen to R1. R1 stated that V5 dragged R1 from the wheelchair and threw R1 onto bed, pushed R1 onto bed, turned R1 side to side, then threw covers on top of her. R1 stated that she told V5 that she doesn't sleep in her clothes. R1 stated that V5 seemed angry with R1. R1 stated that V5 then push R1 side to side again to remove R1's clothes. On 11/10/22 at 11:30am, V3 (nurse) stated that V3 is familiar with R1. V3 stated that R1 transfers from bed to wheelchair via a mechanical lift device. On 11/10/22 at 12:15pm, V4 (Director of Rehabilitation) stated that R1's knees tend to lock when ambulating in physical therapy. V4 stated that R1 has a lot of anxiety, which is her baseline. V4 stated that R1 requires two persons or one very strong person for transfers in therapy. V4 stated that therapy's recommendation is for R1 to be transferred using a mechanical lift device for all transfers by staff. Review of R1's MDS (Minimum Data Set), dated 9/30/22, notes R1 requires extensive assistance of two staff members for all transfers. R1's BIMS (Brief Interview of Mental Status) is 14 out of 15. R1 is able to make needs known. Review of R1's investigation report, dated 10/8/22, notes R1 informed V1 (Administrator) that V5 (CNA) was rough while transferring R1 to bed. R1 stated that V5 refused to transfer R1 using a mechanical lift device. Multiple unsuccessful attempts by V1 to speak with V5 were made. The investigation concluded that V5 did not use proper techniques to transfer R1, even after R1 requested it. Review of R1's PT (Physical Therapy) evaluation, dated 9/23/22, notes R1's static standing balance is poor, R1 requires maximum assistance. R1 requires total assistance with bed mobility and transfers. Review of R1's therapy progress report, dated 10/6/22, notes R1's static standing balance is poor, R1 requires maximum assistance. R1 requires total assistance with bed mobility and transfers. Review of this facility's mobility-ambulation policy, revised 05/2020, notes all residents who are declared safe for ambulation with nursing staff should be mobilized using the appropriate device assigned by physical therapy.

Based on observation, interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition services. The facility failed to obtain food handling and sanitation course completion and competencies for all 3 of their main cooks servicing the entire facility. Findings include: On [DATE] at 10:20 AM, V1 (Administrator) provided surveyor with facility census showing total of 79 residents. An initial tour of the facility kitchen on [DATE] at 10:40 AM showed 3 current cooks with no food handling certificates. On [DATE] at 10:55 AM, V4 (Dietary Manager) was asked to provide food handling certificates for cooks employed but could not provide any for all three of the facility cooks (V6, V7, and V8). Surveyor asked whether any of the cooks obtained previous class instruction on food handling and sanitation, V4 stated, I don't know, I don't have them but they should be with our human resource department. Surveyor asked if the 3 cooks were in charge of cooking for the facility, V4 stated, Yes. They all cook at different shifts and this is the only kitchen we have and it is for the entire facility. On [DATE] at 2:45 PM, V1 (Administrator) stated, I'm aware of the issue in the kitchen. We have one kitchen and it services the entire facility meaning all the resident food comes out of that kitchen. The three cooks (V6, V7, V8) have no current food handling certificates. The human resource person usually maintains these in her records but I could not find the files. We currently also do not have a human resource person but we are in the process of hiring one. Surveyor asked about the cooks' food handling certificates and whether the current cooks had certificates to begin with or whether they had expired, I can't answer that because there were no certificates to be found for any of the three cooks, but I will get them the certificates as soon as possible. Surveyor asked whether the cooks were required to have them to begin with before being utilized in the facility kitchen, V1 stated, I think so. I will either have them take the course which I'm not sure is on-line or in-person but either way I will have them get their food handling certificates as soon as possible. Surveyor asked V1 for any policy or procedures pertaining to dietary personnel requirements but was unable to provide any such policy. V1 instead provided policy for general food preparation and handling.

Based on observation, interview and record review, the facility failed to properly date open food items in the refrigerator and freezer, failed to discard expired egg products and wilted produce items, failed to provide hair nets and wear hair restraints, failed to perform hand hygiene between tasks and prior to putting on gloves for food handling, and failed to maintain all kitchen equipment and overall kitchen area in a clean and sanitary condition. These failures have the potential to affect all 79 residents who receive oral diets from the kitchen. Findings include: On [DATE] at 10:40 AM, V1(Administrator) accompanied surveyor to show where the dietary department was located, V1 entered the kitchen and introduced V4 (Dietary Manager). Surveyor asked where he could obtain a hairnet to wear while in the kitchen and where other staff obtain hairnets prior to entering the kitchen. V4 motioned to the location where hairnets were normally located but there were no hairnets to be worn. V4 motioned to V5 (Executive Chef) to obtain a box of hairnets from the back whereupon V5 came back with a box of hairnets for the surveyor. V4 stated, Sorry this is normally where we place the hair nets and we make sure everyone wears one while they are working in the kitchen. A general tour and review of the kitchen is as follows: Two free-standing double ovens exterior with grease-ridden and had baked on food debris all over the glass and sides of each oven. Inside each of the ovens were blackened and grease-ridden racks that had blackened encrusted crates and food blackened food debris on the bottom of the ovens. Surveyor asked V4 whether the ovens were in use, V4 stated, They work on and off but we aren't really using them. Surveyor asked if they were not using the ovens why the ovens were on and warm, V4 stated, Oh yes sorry we do use them but sometimes they work, sometimes they don't. We have been asking to get them replaced but nothing happens. Immediately behind the double ovens was a flat-top grill that was laden with grease and blackened food debris all over the sides and under the flat top grill. Under the flat top grill was an inch-thick of grease and collection of old food remnants and crumbs that remained in the grease trap. Surveyor asked if the flat-top grill was functioning, V4 stated, Yes. It was broken for about 3 days or so but it is fixed now. Surveyor asked what they use instead while the flat-top grill was inoperative, V4 pointed to the skillet pans and stated, We used those to fry food. Surveyor asked who's responsibility it was to clean the flat top grill and double ovens, V4 stated, Well we do and my staff. Surveyor pointed to the grease, blackened food debris and grease catch, V4 stated, Yes I see that, we should be cleaning that daily after each use. Surveyor asked if he thought this appeared to be the case, V4 stated, No, you're right they are very dirty. Inside the walk-in refrigerator were 9 hard-boiled eggs in a plastic container sitting on the shelf. The eggs were uncovered and undated as to when the eggs were prepared. V4 stated, Those should be dated and covered, I will throw those out. On another shelf were a box of 10 heads of lettuce that all had blackened edges on the leaves. Surveyor asked V4 when he received the shipment of the lettuces because they did not appear fresh as the leaves were wilted and most had blackened and wet edges, V4 stated, We didn't get that delivery that long ago but we normally just remove the bad leaves of the lettuce and we can still use it. On another shelf were a bag of 8 opened pita bread. The bread was dried up and had no open date or use by date. V4 stated, Those should be labeled too. I will take care of that. To the left of the walk-in refrigerator was a prep table housing several plastic containers beneath it. One container marked bread crumbs had a Use by label dated [DATE]; a plastic container of rice with Use by label dated [DATE], and a plastic container of powdered thickener with a Use by label dated [DATE]. Outside each of the containers were scattered remnants of rice, bread crumbs and powdered thickener all on the floor underneath each container. V4 stated to surveyor, I think we can still use these even after the use by date. Surveyor asked the purpose of the Use by label if the date is already a month old, V4 stated, I don't know, we always use it even after the date. Immediately outside the kitchen area V4 was asked what type of room the surveyor was looking at, V4 stated, This is like the pantry area where staff prepares some food and when the refrigerator worked, they get food there to serve to the residents. Surveyor asked about the large double glass door refrigerator he was referring to, V4 stated, That has been broken for as long as I can remember, since I got here so it's over 3 months. We have an order for it for replacement. Surveyor asked if he could provide the service or purchase order for the new refrigerator but was not provided one during the course of the survey. In the pantry area was a large white reach-in refrigerator. Inside the freezer were 4 large containers of uncovered and unlabeled ice cream and sorbet. There were boxes of loose ice cream bars strewed all over the bottom of the freezer which had an inch-thick layer of ice caked all over the sides and bottom of the freezer. Surveyor asked V5 (executive chef) who was standing in the vicinity, V5 stated, Those are 10 gallon of ice cream and sorbet for the residents but yes they should be covered. I don't know why they threw out the cardboard covers on the ice creams. Surveyor asked V5 about the cracked and broken rubber seal on the freezer door to keep the cold air inside the refrigerator, V5 stated, Yes I see that. That is why there's all that frost in the fridge because it loses the cold. Surveyor then asked V4 what is the black colored grime that was all around the rubber seal of the freezer, V4 stated, That looks like mold. This freezer is so old we will get it replaced and I will have them throw this out. At 11:08 AM, Surveyor returned back to the kitchen area to conduct further observations of the kitchen. On the tray line prep table was a metal container showing cooked sausage links and patties piled atop each other forming a mound. The food was left uncovered. V6 (Cook) was asked about the metal container containing the breakfast items, V6 stated, We had this for breakfast and I keep it there just in case we get anyone who needs mechanical soft order. Surveyor asked when the food was cooked, V6 stated, Early this morning for breakfast around 7:30. Surveyor asked whether the items should be covered and why the items should be covered while cooling. V6 stated, Because they can get bacteria? V4 was overheard telling V6 in Spanish to throw out the food since surveyor saw the items in question. V6 took the metal tray and threw out the food. Surveyor asked V4 if this was the normal practice in cooling food items exposed to air and not covered, V4 stated, Well we should be covering them, sorry. container of breakfast meats sitting atop the prep table. V6 was observed with no hair-net and was preparing foods with no gloves or was observed conducting hand-hygiene while handling food. There were no sanitation buckets with cloths to wipe down any surface areas before, during or after the food preparation. V6 was asked about this but stated, I don't know. The 2017 Food Safety and Sanitation ,d+[DATE] Policy states: Policy: All local, state and federal standards and regulations will be followed in order to assure a safe and sanitary department of food and nutrition services. Procedures: 2. Employees c. Employees are required to have their hair styled so that it does not touch the collar, and to wear clean aprons, clothes and shoes. . Hair restraints are required and should cover all hair on the head. d. Employees will wash their hands just before they start to work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds or dirty dishes, and touching face, hair, other people or surfaces or items with potential for contamination. The 2017 Employee Sanitary Practices ,d+[DATE] Policy states: Policy: All nutrition and food service employees will practice good personal hygiene and safe food handling procedures. Procedure: All employees will: 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. The 2017 Hand Washing ,d+[DATE] Policy states: Policy: Employees will wash hands as frequently as needed throughout the day using proper hand washing procedures (and surrogate prosthetic device washing procedures as appropriate). Hand washing facilities will be readily accessible and equipped with hot and cold running water, paper towels, soap, trash cans and signage outlining hand washing procedures. If chemical sanitizing gels are used, staff must first wash hands as outlined below. Procedure: Clean hands and exposed portions of arms (or surrogate prosthetic devices) immediately before engaging in food preparation. 1. When to wash hands: g. During food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks. i. Before donning gloves for working with food. The 2017 Bare Hand Contact with Food and Use of Plastic Gloves states: Policy: Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. Procedure: 4. Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning work with food). The [DATE] Updated Interim Guidance for Nursing Homes and Other Licensed Long Term Care Facilities states: Older adults living in congregate settings are at high risk for infection by respiratory and other pathogens, such as [CONDITION(S)]-CoV2, the CDC stated February 2, 2022. Even as nursing homes and other long-term care facilities resume normal practices, they must sustain core infection prevention and control (IPC) practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and health care personnel (HCP) in order to prevent spread and to protect residents and HCP from severe infections, hospitalization s, and death, The Illinois Department of Public Health, Food, Drugs and Dairies Food Handler Training Version 5 ([DATE]) states: Who is considered a food handler? Food employee or food handler means an individual working with unpackaged food, food equipment or utensils, or food-contact surfaces. Food employee or food handler does not include unpaid volunteers in a food establishment, whether permanent or temporary. The 2017 Food Storage states: Policy: Sufficient storage facilities will be provided to keep food safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure: 14. F. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. 15.c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.

Based on interview, and record review, the facility failed to have effective interventions in place to keep a resident with a history of falls, free from injury after repeated falls. This failure applied to one (R2) of three residents reviewed for falls. This failure resulted in R2 having two major falls with injury while at the facility, resulting in a fractured maxilla and a facial fracture after the second fall. Findings include: R2 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include: Type 2 Diabetes, Repeated Falls, Muscle Weakness (generalized), and Need for Assistance. R2 is no longer a resident at the facility. Nursing Progress Note dated 12/18/21, 13:20 reads: Resident's sister/POA came around 11am and took all resident's belongings including all medications and her wheelchair and said resident is not coming back here. R2's MDS (Minimum Data Set) assessment dated [DATE] documents under Section G (Functional Status) that R2 requires extensive assistance (3) with self performance activities. R2's Fall Risk Screening Tool dated 11/8/21, Summary reads: hx multiple falls in previous nursing home. Resident requires one-on-one care and help with ADLs. Nursing Progress Note dated 12/12/21, 14:37 reads: Unwitnessed fall at 11:10am. Sent to (local hospital) by 911 at 11:17am. At 2:45pm facility received a call from (hospital RN) was informed resident (R2) is coming back. CT of brain and spine were done, negative results, with facial fracture (maxilla) and was told orders for her (R2) to see a doctor will be sent with her when she returns. Hospital record dated 12/12/21 documents that (R1) was sitting in wheelchair and fell out; Diagnosis: closed fracture of maxilla. Facility incident report dated 12/12/21 at 11:10am documents R2 was in the dining room doing an activity. Activity aid passed drinks to R2 turned to another resident to pass drink, heard a noise, and observed R2 lying on the floor on her left side. R2 returned from ER with the diagnosis of fracture of maxilla. Investigated, and updated the care plan. R2's Care Plan includes: Resident came to the facility from (named ALF, assisted living facility) d/t frequent falls, the family have decided to have her transition to SNF (skilled nursing facility) setting (Date Initiated: 12/18/21) . Interventions include: Supervise the resident while in the dining room. Encourage her to stay/keep her near to nursing station if not sleeping or not in an activity (Date Initiated: 12/16/21). Bed in low position (Date Initiated: 11/16/21) Call light positioned for easy access (Date Initiated: 11/16/21). R2's Fall Risk Screening Tool dated 12/12/21, Summary reads: Fall risk related to cognitive impairment, no safety awareness. Decreased strength and endurance to all extremities. Needs extensive assist with transfer, and mobility. R2's Fall Risk Screening Tool dated 12/16/21, Summary reads: This is the second fall this month this resident has experienced. Resident requires constant monitoring and R2 is a high fall risk. Resident should be placed in a room closer to the nurses station for better supervision. Nursing Progress Note dated 12/16/21, 15:45 reads: Writer was called to the dining room due to loud sound, resident was found on the floor facing down with her head on the pillow. Resident has a raised protruding area on her left side of the forehead. Resident's nose and mouth were covered in blood. Resident was found on prone position. Writer and oncoming shift nurse cleansed her face and applied ice to the raised protruding area. Mid-shift nurse called 911. Tooth had fallen out was placed in a zip lock bag. Resident kept stating she couldn't breathe and wanted to be sat up, resident also stated she fell . 911 was called and paramedics came and assisted resident to the stretcher from the floor. Nursing Progress Note dated 12/16/21, reads: At 8:15pm, writer called local hospital to follow up resident's status, spoke with emergency department staff and said resident is admitted due with facial fracture. MDS Coordinator and Executive Director made aware of resident's status. Facility reported incident dated 12/16/21 reads: Resident was found on the floor in the dining room, facing down with her head on the pillow. Resident was with other residents in the dining room for an activity before the incident. Assessment done. Resident alert, oriented to baseline. No change in level of consciousness, has a raised protruding area on her left side of forehead. Resident's nose and mouth were bleeding. Cleansed her face and applied ice to the raised protruding area. Called 911. Sent to local hospital ER for further evaluation and treatment .Root cause analysis done and care plan updated. Call placed to (local hospital). Resident admitted with facial fracture. On, 2/5/22 at 12:18pm, during interview with V2 (RN/Infection Preventionist) and V3 (Director of Nursing), surveyor asked what was meant by one-to-one assistance and close monitoring meant (per R2's care plan). V2 stated, nurses and CNA's (Certified Nurse Aide) should have close monitoring if the resident needs one-to-one assistance. V3 then added it's not reasonable to assign one-to-one staff to residents, surveyor then pointed out that this is precisely what R2's fall assessment documented that the resident needed. V3 added that she was not working here at that time. V2 added staff were present when R2 had the fall but there were more residents in the room than just R2. Surveyor asked if it would have been reasonable to think that R2 required more supervision and attention from staff, considering she had just had a fall with major injury just four days prior to (12/16/21) and if there should have been more than one staff with multiple dependent residents in the room; V2 and V3 agreed there should have been more supervision for R2 given her history. V2 stated, during the second fall, the activity aide was in the dining room within seconds after she fell ; normally there is an activity aide monitoring the residents in the dining room; if someone is high risk we keep them where we can visually see. Surveyor pointed out if someone can visually see the resident but is not in the same room, how are they expected to prevent a fall from happening. V2 and V3 agreed if not close enough to the resident, fall's cannot be prevented. Additionally surveyor asked how can the activity aide monitor the residents for falls (for example) if they are distracted leading the activity. V2 and V3 agreed it could be difficult to do. Surveyor pointed out during the course of this survey, multiple residents who were dependent on staff were observed unsupervised in the dining room. V2 and V3 agreed the CNA should be in the dining room monitoring. 2/5/22 at 4:00pm, surveyor asked V1 (Administrator) what is the expectation in regards to supervision for dependent residents being in the dining room unsupervised and V1 stated that normally she would expect a staff to at least be in the dining room monitoring the residents; however, she was not working at the facility at the time that R2 had these falls and they may have been short staffed due to COVID but staffing is not currently an issue.