Every finding on record at Elevate Care Abington

Based on interview and record review, the facility failed to protect one resident's (R1) right to be free from physical abuse, out of four residents investigated, by not adhering to its own abuse prevention policy when a staff member kicked R1 on his leg while he was lying in bed. Findings include:R1 is an eighty-seven-year-old resident of the facility with a Brief Interview for Mental Status (BIMS) score of 14/15, and medical diagnosis including but not limited to peripheral vascular disease; encounter for surgical aftercare following surgery on the genitourinary system; benign prostatic hyperplasia with lower urinary tract symptoms; multiple sclerosis; hypertensive heart disease without heart failure; atherosclerotic heart disease of native coronary artery without angina pectoris; trigeminal neuralgia; history of falling; personal history of transient ischemic attack, and cerebral infarction without residual deficits; and adjustment disorder with depressed mood. On 04/29/2026 at 12:03 PM, R1 said one day about two months ago, he was yelling for assistance because he could not find his call light. R1 said V3 (CNA) entered his room and told him to stop yelling and to be quiet. R1 said V3 then kicked him twice on his leg. R1 said it felt like it was a kick to get his attention. R1 said he then thought to himself, I'm not able to defend myself. R1 said V3 left without assisting him. On 4/29/2026 at 12:12 PM, V4 (Caretaker) said he spoke with V3 on 02/02/2026, and V3 told him he kicked R1, who was in bed. V4 said V3 told him he and R1 were a little frustrated; so, in frustration, V3 tried to kick R1's bed but ended up kicking R1's leg, instead. V4 said he then told V6 (RN). On 04/29/2026 at 12:43 PM, V3 said he did not recall the alleged incident with R1; however, since R1 had always been in bed whenever V3 had been in his room, it was possible he may have run into his bed, inadvertently. On 04/30/2026 at 10:47 AM, V1 (Administrator) said R1 told her he did not like V3's approach. On 04/30/2026 at 12:17 PM, V6 (RN) said on 02/01/2026, at around four or five in the afternoon, V7 told her R1 had said V3 had kicked him twice a couple days back, on his foot. On 04/30/2026 at 12:35 PM, V7 (Family Member) said R1 complained to her one CNA at the facility was not as nice as the others. V7 said R1 first told V4 (Caretaker) V3 kicked him, and then V4 told her. V7 said she then spoke with R1, and he told her the same story, more than once. In separate interviews on 04/30/2026 between 10:47 AM and 12:17 PM, V1, V5 (Social Services Director), and V6 said they did not speak with V4 about R1's allegation against V3. The facility's Abuse and Retaliation Policy Prevention Program (January 2026) states, in part, This facility affirms the right of our residents to be free from abuse. This will be done by establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment.

Based on observation, interview, and record review, the facility failed to ensure proper infection control guidelines were being followed for residents on transmission-based precautions. This failure has the potential to affect all 142 residents residing in the facility.Findings Include:Facility Census dated 3/9/2026 shows there are 142 residents currently residing in the facility.On 3/9/2026 at 12:15PM, V9 (Registered Nurse) entered R18's room with a disposable tray containing a glucometer, bottle of test strips, alcohol wipes, cotton balls, and a syringe filled with insulin. Hand hygiene was not performed upon entering the room and PPE's were not donned according to signage outside of R18's room. V9 was then observed leaving R18's room with disposable tray in hand which contained the glucometer, bottle of test strips, and used needle in packaging.It is to be noted that per Transmission Based Precautions (TBP) isolation list and R18's physician orders dated 3/1/2026, R18 is on contact isolation for MRSA in the blood.At 12:35PM, V15 (CNA) entered R86 and R105's semi-private room. Signage outside of the door showed both residents to be on contact precautions with N95 mask to be worn. No PPE's were donned by V15 prior to entering the room.A few moments later, V15 exited the room with a reusable water bottle and took it into the nourishment room. When V15 exited nourishment room, V15 said we do not typically use reusable water bottles but disposable cups. V15 could not answer proper protocol for refilling reusable water bottles when a resident is on isolation.At 3:00PM, V11 (CNA) and V12 (CNA) were observed transferring R141 back to bed. R141 was noted to have enhanced barrier precautions sign outside of door. It is to be noted that while transferring R141 back to bed and touching catheter, no PPE's were worn by V11 and/or V12.On 3/11/2026 at 11:35AM, V9 was observed exiting R4's room with disposable tray containing items for accuchecks and test strips. V9 said I just checked R4's blood sugars. Asked what V9 was expected to do with equipment after checking blood sugars. V9 said I will throw the disposable tray in my medication cart garbage and sanitize the equipment before reusing.It is to be noted that R4 is on isolation for testing positive for COVID.At 1:45PM, V4 (Infection Preventionist) said when entering a room where residents are COVID positive, the staff should wear a gown, gloves, N95, and face shield prior to entering the room. If the resident is on contact isolation for something other than COVID, the staff should wear a gown and gloves prior to entering the room. For residents who are on enhanced barrier precautions, the staff should be wearing a gown and glove for any time they are to come in contact with the resident.V4 said when staff are exiting these residents rooms, all items that are disposable should be discarded immediately, and any equipment should be immediately sanitized. Staff should provide residents on isolation with disposable water cups. If a reusable cup exits the residents room, it is considered contaminated.Facility policy titled Contact Precautions states in part but not limited to the following: Gloves should be worn when entering the room and while providing care for the resident. Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately. A gown should be donned prior to entering the residents room and removed before leaving. When indicated, equipment should be carried into a residents room with a disposable tray and the tray should be discarded in the room.Facility policy titled Droplet Precautions states in part but not limited to the following: Residents will require the use of PPEs for high-risk activities such as: bathing, dressing, toileting, transferring residents, linen changes, handling medical devices, etc. PPEs required are as follows: gown and gloves. Persons expected to encounter these circumstances are to don PPEs in accordance with the activity that they will be encountering when caring for a resident.

Based on observation, interview and record review, the facility failed to ensure house stock medications, insulin and eyedrops were labeled and dated when opened; failed to properly manage medications with expired orders and failed to appropriately store controlled medication per policy. These deficiencies affect six (R20, R100, R117, R122, R132 and R148) of six residents in the sample of 44 reviewed for medication storage and labeling.Findings include:On [DATE] at 2:30 PM, the following were observed during medication cart and storage assessment:2 South medication cart: Two boxes of Lorazepam were found for R117; one box dated [DATE] and the other dated [DATE]. No current orders are present for either box. Medication Requisition Form in cart binder for R117's Lorazepam 2 mg (milligrams) reads: a 0.25 mg dose was given on [DATE], however, medication was unopened/sealed in cart. Record review of Electronic Medication Administration Record (EMAR) indicated that this medication was most recently ordered and discontinued on [DATE]. House stock medications were on top and bottom drawers were opened, undated. Lispro Insulin for R122 with an expiration date of [DATE] was found.2 East medication cart: An opened Lispro Insulin multi-dose vial was observed with no name, no date, no box. R20's Glargine Insulin multi-dose vial was opened, undated, with vial having an expiration date of [DATE]. Risperidone 0.5 mg tablet was found in a small medication crusher plastic bag: no name and a handwritten label of Risperidone 0.5 mg tablet. V9 (Registered Nurse, RN) stated that she was unaware who this medication belonged to and that she would dispose of it. V9 was asked regarding expectation of the facility related to medication labeling. V9 stated that house stock medications are to be labeled with an open date and an expiration date. On [DATE] at 2:40 PM, second floor medication storage room was checked with V10 (RN). A multi-dose vial of Tubersol with no expiration date was observed. The Tubersol multidose vial had an open date of [DATE]. V10 advised that she is unaware of the policy regarding how long this medication can be open prior to needing to be discarded. An unopened Lorazepam box for R148 was found in cabinet under the sink. The cabinet was unlocked. V10 stated she has never seen this medication before. Upon record review, R148 was discharged on [DATE]. V10 stated that she believed this medication should not be under the sink, unlocked.On [DATE] at 3:20 PM while observing 2 [NAME] medication cart with V7 (RN), Latanoprost eye drop solution for R132 was opened with no open date or expiration date. Glargine Insulin pen for R100 was open and did not have an open date or expiration date. V7 stated that medications should have an open date with a correlating expiration date. On [DATE] at 10:25 AM, V2 (Director of Nursing/DON) was interviewed regarding medication storage and labeling. V2 stated that all medications should be stored and locked in the medication room and medication cart and should have appropriate labels when opened. Eyedrops, inhalers, insulin and any other multi dose vial should have dated and discarded when expired. V2 stated that the expectation for multi-dose insulin vials is that they are dated when they are opened and given an expiration date according to medication specific parameters (Ex: Insulin Glargine is good for 28 days following opening). Insulin multi-dose vials are to be discarded following the expiration date on the bottle, if no expiration date is present, insulin vials should be discarded. V2 stated that all medications are to be dated when opened and given an appropriate expiration date. V2 stated that controlled medications in medication room should be kept behind two locks and medications that are required to be refrigerated must be kept in the locked refrigerator. V2 stated that R148's Lorazepam found underneath the sink, unlocked and not refrigerated was inappropriate. Regarding R117's Lorazepam, V2 stated that he would investigate this further but did not return with further information about this incident. V2 stated that the Tubersol multi-dose vial is to be labeled when opened and given an appropriate expiration date. When asked how many days this vial is good for, V2 advised he would have to investigate it as he was unaware at this time. V2 stated that any medication removed from packaging is to be either given to the resident or discarded. V2 stated that the Risperidone 0.5 tablet found inside a small plastic bag was an inappropriate action. At 3:00 PM, V2 stated that the Tubersol is good for 30 days after opening.Facility's Policy titled, Guidelines for the Storing of Medications dated [DATE] reads in part but not limited to the following: Medications are stored in the containers in which they are received. Transfer between containers is performed only by the issuing pharmacy. All discontinued, outdated, or deteriorated medications will be destroyed or sent back to the pharmacy. Medications requiring refrigeration must be stored in the refrigerator located in the drug room at the nurse's station. All controlled drugs are stored under double-lock and key.Facility presented the Insulin and Injectable Diabetic Medication Chart dated 2016 reads in part but not limited to the following:Lantus (Insulin Glargine) vial/pen expired 28 days after openingHumalog (Insulin Lispro) vial/pen expired 28 days after opening

Based on observation, interview, and record review, the facility failed to ensure a urinary catheter was positioned to maintain a downhill flow of urine in accordance with facility policy. This deficient practice affected one (R141) of three residents in the sample of 44 reviewed for catheter.Findings include:R141 is an [AGE] year-old male with diagnoses of Retention of Urine, Unspecified; Obstructive and Reflux Uropathy, Unspecified; and Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms.R141's physician's orders dated 02/26/2026 read: Suprapubic Catheter: Diagnosis for Suprapubic Catheter: Neurogenic Bladder/ Obstructive Uropathy.On 03/10/2026 at 1:30 PM, R141 was sleeping in his room, laying with head of bed slightly elevated, with no visible catheter. At this time, surveyor asked V10 (Registered Nurse, RN) to assist with locating R141's catheter. V10 came to room to help surveyor locate catheter. Upon assessment, the bag of the suprapubic catheter was found strapped to the resident's (R141) right leg and had bright red blood inside. V10 stated that she believes the bag is supposed to be hanging at the bedside to help reduce the risk of urine backflow, which could cause a UTI (urinary tract infection).On 03/11/2026 at 10:30 AM, an interview with V2 (Director of Nursing/DON) was conducted regarding catheter care policies. V2 stated that the expectation for staff is to ensure the catheter bag is kept hanging below the bladder level to prevent backflow of urine. V2 stated that whether the resident is in bed or chair, the bag is maintained lower than the bladder level. V2 also stated that if a nurse assessed a resident's catheter bag not being in the proper position, it would be expected that the nurse would change the bag and hang below the bladder level at that moment. R141's care plan on suprapubic catheter recorded: Intervention: Position catheter bag and tubing below the level of the bladder. Collection bags have backflow prevention devices which are effective for short periods such as during transfers and bed mobility.Facility's policy titled Urinary Catheter Care, dated 02/14/2019 reads in part but not limited to the following: Catheters shall be positioned to maintain a downhill flow of urine to prevent a back flow of urine into the bladder or tubing, during transfer, ambulation and body positioning.

Based on observation, interview, and record review the facility failed to ensure implementation of appropriate infection prevention and control practices during medication administration including disinfecting of medical equipment use, providing care to a resident on Enhanced Barrier Precaution (EBP), and performing hand hygiene after removing gloves. The facility also failed to place the nebulizer mask and tubing in plastic bag when not in use. This deficiency affects four (R8, R54, F179 and R329) residents in the sample of 25 reviewed for Infection Control Prevention and Control Management. Findings include: On 4/1/25 at 10:57AM, Observed R54 up in wheelchair in his room. R54 is on Enhanced barrier precaution. Observed urinary drainage bag with visible yellow sediments in the tubing hanging over the grab bar next to emesis basin in the bathroom. V11 LPN (Licensed Practical Nurse) said that CNA (Certified Nurse Assistant) change R54's urinary catheter bag to leg bag when he is up in wheelchair. V11 said that emesis basin should not be placed next to the urinary drainage bag. Observed emesis basin is dirty with dried white colored toothpaste inside. On 4/1/25 at 11:35AM, Observed V15 LPN took portable Blood Pressure (BP) machine equipment from another resident in 3 north unit. V15 went to R8 with medication cart and BP equipment. V15 did not disinfect the BP cuff before placing it on R8's left arm and obtained her BP. Informed V15 of observation made. She said BP equipment should be clean/disinfect before and after taking resident's BP. On 4/2/25 at 8:32AM, V19 RN (Registered Nurse) gathered medical equipment for vital signs (portable wrist BP machine, pulse oximeter, and oral thermometer) from her medication cart and prepared medications inside R179's room. R179 is on Enhanced barrier precaution. V19 entered the room without donning appropriate PPE. V19 is wearing mask, she donned gloves when entering the room. She placed the medical equipment for vital signs on bedside tray table. V19 placed the BP wrist on R179's left wrist, then placed the pulse oximeter on left index finger and took oral temperature. After obtaining vital signs, she then administered prepared medications. She brought her medical equipment on top of the medication cart. She wiped the medical equipment with disinfectant wipes. On 4/2/25 at 8:50AM, Informed above observation with V19 RN and V17 Restorative Nurse. V19 said that she did not don gown because she was just taking vital signs and performing oral administration of medication. V17 Restorative Nurse said that appropriate PPE is observed during medication administration and taking vital signs in EBP. V17 said that they should follow manufacturer recommendation in using disinfecting wipes which is contact time of disinfectant of 3 minutes. On 4/2/25 at 11:01AM, Informed V3 Infection Preventionist of above observation. V3 said that vital signs equipment is only disinfected after using and not before. V3 said that no need to don PPE when taking vital signs and medication administration to resident on EBP. V3 said that disinfectant wipes manufacturer recommended keeping wet for 3 minutes. V3 said that emesis basin should not be placed next to urinary drainage bag in the bathroom. On 4/2/25 at 11:16AM, Informed V2 DON (Director of Nursing) of above observation. V2 said that they should disinfect medical equipment for taking resident vital signs before and after using. V2 said that they should don appropriate PPE when taking vital signs and administration of medications to resident on EBP. V2 said that they should not place emesis basis next to urinary drainage bag in the resident's bathroom. They placed order in resident's chart for resident on transmission-based precaution including EBP. On 4/3/25 at 9:40AM, Review R8's medical record with V3 Infection Preventionist. Informed V3 that R8 does not have order for Enhanced Barrier Precaution. R8 has colostomy and receiving Triamcinolone Acetonide cream treatment for itching to upper back, BUE, shoulder and BLE. R8 has red rashes on her upper extremities. Facility's policy on Enhanced Barrier Precaution (EBP) revision 4/1/24 indicated: Purpose: To minimize the risk of acquiring, transmitting, or complications resulting from multi-drug resistant organism (MDRO) colonization among residents in this setting. (Contact precautions would be warranted over EBP when there is risk of transmission of an actively infectious agent) Guidelines: *Residents will require the use of personal protective equipment (PPE) for high-risk activities such as: -Any situation where expected contact of blood, bodily fluids, skin breakdown, or mucous membrane will be encountered. *PPE required: -Gown -Gloves *Persons expected to encounter these circumstances are to don PPE (gown and gloves) in accordance with the activity that will be encountered when caring for the resident. Facility's policy on Cleaning & Sanitizing- wheelchairs and other medical equipment revision 1/25/18 indicated: Purpose: To assure that devices are cleaned and sanitized on a regular or as needed basis. Guidelines: 5. Devices/equipment used for more than one resident shall be cleaned between each resident. Manufacturer's recommendation for Germicidal bleach wipes (surface cleaning chemicals and disinfectants) indicated: Overall contact time of 3 minutes. Contact time for a disinfectant is the amount of time a surface must remain wet with the product to achieve disinfection. 49871 On 4/1/2025 at 10:55 AM, V4 (Director of Guest Relation) removed and discarded his gloves then proceeded to resident room [ROOM NUMBER] without performing hand hygiene. On 4/1/2025 at 10:56 AM, V4 stated he performed hand hygiene before putting gloves on but not after removing it. V3 (Infection Control Nurse) said hand hygiene should be performed before and after removing gloves. On 4/2/2025 at 9:40 AM, V2 (Director of Nursing) said hand hygiene should be done after removing gloves and if hands are visibly soiled then hand washing with soap and water need to be performed. On 4/1/2025 at 11:00 AM, R329 seated on the wheelchair said she gets breathing treatments. Nebulizer treatment machine on top of the nightstand table with mask and tubing attached to the machine. On 4/1/2025 at 11:02 AM, V3 (Infection Control Nurse) said nebulizer kit, mask and tubing, should be kept in a ziplock/plastic bag for privacy. Mask should be rinse and air dry after each used. On 4/2/2025 at 9:40 AM, V2 said nebulizer mask and tubing should be kept in a ziplock bag when not in used for infection control. Nebulizer mask should be rinsed and air dry after each used. Review of Admission record read: admitted [DATE], Diagnosis Information include PNEUMONITIS DUE TO INHALATION OF FOOD AND VOMIT; Order Summary indicate Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 dose inhale orally every 6 hours for SOB while awake. Care Plan Report indicate Administer respiratory treatment (Ipratropium-Albuterol) as ordered. Policy and Procedure Title: Hand Hygiene/Handwashing, Revisions: 1-10-18 Definition: Hand hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel). Guidelines: When to Wash Hands With Soap and Water ONLY (may use Alcohol Based Hand Sanitizer for All Other): After glove removal Policy and Procedure Title: Oral Inhalation Administration, Date: 10/25/2014 Purpose: To allow for safe, accurate, and effective administration of medication using an oral inhaler (with or without a spacer/chamber) or nebulizer. Nebulizer - Administering Medications through a Small Volume (Handheld) Nebulizer U. Rinse and disinfect the nebulizer equipment according to manufacturer's recommendations, or: 1. Wash pieces (except tubing) with warm, soapy water daily. Rinse with hot water. Allow to air dry completely on paper towel. W. When equipment is completely dry, store in a plastic bag with resident's name and date on it.

Based on observation, interview, and record review the facility failed to ensure that no medications are kept at the resident's bedside without physician order. The facility also failed to assess a resident for safe medication self-administration. This deficiency affects one (R8) of three residents in the sample of 25 reviewed for Medication safety. Findings include: On 4/1/25 at 11:40AM, While observing V15 LPN (Licensed Practical Nurse) administering oral medication to R8 observed the following medications not labeled on her bedside tray table: one (1) triamcinolone acetamide lotion 0/1% 60 ml, two (2) nasal (deep sea) spray bottles and (3) Caladryl lotions. R8 is alert, oriented x 3 and can verbalize needs to staff. R8 said that she has been taking these medications in her room. She said she has rashes to her both hands/arms, as she pulled up her sleeves and showed her rashes with redness. She said that she applied triamcinolone and caladryl for her rashes and itchiness on both arms/hand every day and as needed. She said she uses the nasal spray 2- 3 times per day and as needed. She said that nurses are aware that she has been taking all of these medications. V15 LPN did not respond. On 4/1/25 at 3:07PM Informed V2 DON (Director of Nursing) of above observation. V2 said that a resident is not allowed to keep medication at the bedside without physician order. V2 said that resident self-administration of medication assessment should be completed to check if R8 is capable of self-administration of medication. Informed V2 DON that R8 does not have an order for Nasal (deep sea) spray and caladryl lotion. R8 does not have an order to keep medications at bedside. No resident self-administration of medication assessment was completed by Interdisciplinary team (IDT). She was not care planned for medication self-administration. R8 was admitted on [DATE] with diagnosis listed in part but not limited to Acute and chronic respiratory failure, Congestive heart failure, Paraplegia, Congenital deformity of spine, Spina Bifida, Allergic rhinitis. Active physician order sheet indicated Triamcinolone acetonide external cream 0.1% apply to upper back, BUE, shoulders, BLE topically every 8 hours as needed for itching. No order for Nasal (deep sea) spray and caladryl lotion. No order to keep medication at bedside. No resident self-administration of medication assessment completed by IDT. Facility's policy on Self- Administration of Medication effective 4/2014 indicated: Purpose: To establish guidelines concerning the self-administration of drug. General Guidelines: 1. A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing by the attending physician. 2. Should the resident's attending physician permit the resident to administer his/her medications, the following condition should apply: c. A self-administration of medications assessment will be completed that indicates that the resident is capable of self-administering drugs. Facility's policy on Medication Storage revision date 7/2/19 indicated: Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes, and needles. Guidelines: 13. Bedside Medication Storage: 13.1 Facility should not administer/provide bedside medications or biologicals without a physician/ prescriber order and approval by the interdisciplinary care team and facility administration. 13.2 Facility should store bedside medications or biologicals in a locked compartment within the resident's room. Facility's policy on Resident rights reviewed 1/4/19 indicated: Purpose: To promote the exercise of rights for each resident. Guidelines: Notice of resident rights will be provided upon admission to the facility. These rights include the resident's right to: *Self-administer medication, if the IDT care planning team determines it is safe.

Based on observation, interview, and record review the facility failed to ensure ongoing assessment and monitoring are implemented to identify and report new open pressure ulcer for a resident who has history of pressure ulcer. The facility failed to notify the physician for appropriate treatment order. The facility failed to implement pressure ulcer prevention policy by not providing specialty mattress. This deficiency affects one (R22) of three residents in the sample of 25 reviewed for Pressure ulcer/Wound Prevention Management. Findings include: On 4/1/25 at 2:17PM, V16 (R22's Family member) said that R8 has pain on her buttocks, but she does not have pressure sore. The nurses applied cream and foam dressing for protection. Surveyor called V6 Wound Care Nurse to check on R22 sacral area. On 4/1/25 at 2:32PM, V6 Wound nurse repositioned R22 to her left side lying position to check skin integrity on R22's sacral area. Observed foam dressing applied to right buttocks. But observed open wound stage 2 /full thickness on sacrococcygeal area, 100% red tissues with whitish color/maceration on peri wound. V6 said it is a healed pressure ulcer. V6 said, he works on the floor and relieved V23 Wound Care Coordinator (WCC) to perform wound care. V6 said that he has not provided wound care to R22 today. V6 said, he has not seen R22 since Thursday last week. V6 said, V23 WCC applied the wound dressing yesterday. Surveyor called V18 ADON (Assistant Director of Nursing) to show new open wound observation on sacral area. V11 LPN (Licensed Practical Nurse) said that the treatment nurse does the wound treatment to R22. V11 is not aware that R22 has new stage 2 pressure ulcer on sacrum area. V11 said that CNA did not report to him that R22 has new open wound. On 4/1/25 at 2:55pm V6 and V18 repositioned R22 to left side lying position to assess skin integrity of sacral area. V18 said R22 has new stage 2 pressure ulcer on sacrum area. V18 measured open wound and obtained 0.5x 1x0.1 cm., 100% red tissue with maceration on peri wound. V18 said that when there is a new open wound, it should be assessed, notify physician for appropriate wound treatment, inform the family, document, and updated the care plan. R22 is readmitted on [DATE] with diagnosis listed in part but not limited to Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease or end stage renal, Parkinson disease, Dementia, Osteoarthritis and Dependence on oxygen supplement. Most recent Braden/skin assessment dated [DATE] indicated that she is at risk for developing skin impairment. Active physician order sheet indicated Sacrum: calmoseptine cream, foam dressing every day shift. Comprehensive care plan indicated that she is at risk for alteration in skin integrity related to medical diagnosis, fragile skin, incontinence of bowel, incontinence of urine, limited joint mobility and poor skin turgor. R22's March 2025 Treatment administration Record (TAR) indicated daily treatment to sacral area. Last wound assessment done on 12/23/24 indicated incontinence MASD (Moisture Associated Skin Disorder) active, erythema, pale pink non granulating 100%, no exudate, skin intact. No documentation found in chart after 12/23/24. Wound assessment completed on 4/1/25 by V18 ADON after surveyor identified open wound /Stage 2 pressure ulcer on sacrum indicated facility acquired pressure ulcer on 4/1/25, 100% pink/red granulating tissue, no exudate, macerated peri wound with attached and distinct edges, measures 0.5cm x 1cm x 0.1 cm. On 4/3/25 at 10:50AM, V23 Wound Care Coordinator said she does the wound treatment, assessment, and wound measurement, and makes wound rounds with the wound care physician. V23 said V18 develops and updates the wound care plan. V23 said that she and V6 does the treatments for R22. V23 said, R22 does not have an open wound, they apply calmoseptine cream and foam dressing to sacrum as protection because she is at risk. She said that she did R22's wound treatment on 3/31/25 at 5:00AM and her skin is intact. V6 relieves her when she is off. Reviewed R22's medical records with V23. Informed V23 that R22's last wound assessment was done on 12/23/24 and indicated active MASD (Moisture associated skin disorder) with erythema on sacrum, no open sore. No documentation was found indicating healed MASD with no erythema. Informed V23 that she and V6 are providing daily treatment to her sacrum but no weekly skin documentation on the sacral area. Informed V23 that specialty mattress was not utilized as preventive measures; not until surveyor presented concern. Informed V23 of concerns identified that they failed to ensure ongoing assessment and monitoring are implemented to identify and report new open pressure ulcer of resident who is at risk for developing and has history of pressure ulcer. The facility failed to notify the physician for appropriate treatment order in a timely manner. Facility's policy on Pressure ulcer prevention revision dated 1/15/18 indicated: Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. May use lotion on dry skin. 9. Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss, alternating pressure, etc., may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple stage 2 wounds or one or more stage 3 or stage 4 wounds. Facility's policy on Pressure injury and skin condition assessment revision 1/17/18 indicated: Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other ulcer and assuring interventions are implemented. 4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. 6. Care givers are responsible for promptly notifying the charge nurse of skin breakdown. 7. At earliest sign of a pressure injury or other skin problem, the resident, legal representative and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes.

Based on observation, interview and record review the facility failed to ensure an oxygen nasal cannula was properly in place for a resident who has an order for oxygen supplementation. The facility failed to change the empty concentrator's humidifier bottle in a timely manner. The facility also failed to follow physician order in administration of oxygen. This deficiency affects 3 (R22, R38 and R81) residents in the sample of 25 reviewed for Oxygen/Respiratory Management. Findings include: On 4/1/25 at 11:00AM, Observed R22 sitting in a wheelchair with oxygen not properly placed. The nasal cannula is placed on her right cheek. Oxygen tubing is dated 3/29/25 and is connected to an oxygen concentrator with a humidifier bottle that is empty. Showed observation to V11 LPN (Licensed Practical Nurse). He placed the oxygen cannula to R22's nasal/nostril and said he will replace the oxygen humidifier. On 4/1/25 at 2:17PM, Observed R22 with oxygen via nasal cannula at 2.5 LPM (liters per minute) with an empty humidifier bottle. V11 did not replace the empty humidifier bottle when observed empty this morning. Showed observation to V11. On 4/2/25 at 11:16AM, Informed V2 DON (Director of Nursing) of above observation. V2 said that humidifier is needed to prevent nasal dryness from oxygen usage. V2 said that oxygen humidifier bottle is replaced once the water is emptied. The oxygen via nasal cannula should be placed properly into resident nostrils to provide oxygen. R22 was admitted on [DATE] with diagnosis listed in part but not limited to Chronic diastolic congestive heart failure, Dependence on supplemental oxygen, Atrial fibrillation, Anemia. Active physician order sheet indicated Oxygen at 2LPM per nasal cannula continuously. Monitor every shift. Comprehensive care plan indicated she needs oxygen and respiratory treatment for shortness of breath/wheezing. Intervention: Provide oxygen as ordered. Monitor saturation every shift and as needed. Change oxygen tubing, humidifier bottle and oxygen tubing plastic holding bag as ordered. Facility's policy on Oxygen therapy: Purpose: To deliver oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. Indications for oxygen use via nasal cannula include: *Reverse the effects and symptoms of hypoxia *Decrease the work of breathing *Decrease the work of the heart Policy: It is the policy of this facility that oxygen shall be used in a safe and effective manner in accordance with applicable rules and regulations and the standard of care. Equipment: *Humidifier *Flow meter *Delivery device (nasal cannula) *Oxygen source *NO smoking sign Procedure: I Physician order A. Verify physician order II Set up and administration of oxygen B. 2. Nasal cannulas should fit unto the nostrils unless contraindicated. 49871 On 4/2/2025 at 11:05 AM, R38 seated on his wheelchair doing active exercise for his legs and not using oxygen. Oxygen tubing and cannula inside the nightstand drawer, not stored in a plastic bag and humidifier/bubbler with a date of 3/22/25. On 4/2/2025 at 11:07 AM, V21 (Registered Nurse) said oxygen cannula should be put in a plastic bag when not in use and humidifier/bubbler should be changed as needed. On 4/2/2025 at 11:15 AM, V2 (Director of Nursing) stated all oxygen humidifiers need to be changed every 7 days and oxygen appliance should be stored in plastic bag when not in use for infection control. Review of Admission record read: admitted [DATE], Diagnosis Information include CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE; OBSTRUCTIVE SLEEP APNEA; Order Summary indicate Oxygen PRN NC Flow__2__ to Keep Sats Greater Than_ 92% as needed for Low O2 Sat; Care Plan Report indicate Provide oxygen as ordered. Monitor saturation as ordered. Change oxygen tubing, humidifier bottle, oxygen tubing plastic holding bag as ordered. On 4/1/2025 at 11:10 AM, R81 in bed with oxygen per nasal cannula at 4.5 liters per minute. R81 is using a concentrator with attached humidifier dated 3/22/25 and bottle is less than 1/4 filled. On 4/1/2025 at 11:15 AM, V6 (Wound Nurse) checked R81's physician order indicating R81 to have continuous oxygen at 3 liters per minute. V6 stated the oxygen humidifier bottle should be changed as needed. V6 stated humidification is used to keep nasal passages from drying out. On 4/2/2025 at 9:40 AM, V2 (Director of Nursing) stated all oxygen humidifiers need to be changed every 7 days and when humidification water level is low, about less than 1/4 filled. Review of Admission record read: admitted [DATE], Diagnosis Information include ACUTE RESPIRATORY FAILURE WITH HYPOXIA; DEPENDENCE ON SUPPLEMENTAL OXYGEN; CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE. Review of Order Summary indicate Oxygen At 3 Liters/Minute Via nasal cannula; Continuously; Care Plan indicate Interventions: Oxygen at 3 Liters/Minute via nasal cannula; Continuously; MDS (Section O - Special Treatments, Procedures, and Programs) indicate Respiratory Treatments C1. Oxygen Therapy while a resident. Policy and Procedure: Title: Oxygen Therapy, no date Policy: It is the policy of this facility that oxygen shall be used in a safe and effective manner in accordance with applicable rules and regulations and the standard of care. Procedure: I. Physician Order A. Verify physician's order II. Set-up and administration of oxygen B. Attach the nasal cannula/mask to the oxygen source and turn the flow meter to the ordered flow rate. Policy and Procedure: Title: Equipment Replacement - Disposable - Nursing; Revisions 1/16/18 Purpose: Equipment will be changed following established schedules to prevent contamination. Guidelines: 1. Oxygen/Nebulizer b. Check water levels in humidifier jar every shift and change humidifier jar every 7 days

Based on observation, interview, and record review the facility failed to lock the medication refrigerator and record the date when medication was opened. This deficiency affects one of two medication storage rooms and one of four medication carts reviewed for Safe medication storage and labeling. Findings include: On 4/1/25 at 9:40AM, Checked second floor medication storage room with V8 RN (Registered Nurse). Observed medication refrigerator unlocked. V8 said that medication refrigerator in the medication room should be locked. On 4/1/25 at 10:22am Checked 3 North medication cart with V11 LPN (Licensed Practical Nurse). Observed R76 's Gentamycin eye drops solution opened but not dated. Observed R18's Combigan 0.2/0.5% eye drop solution opened but not dated. V11 said that medication should be dated when it was opened. On 4/1/25 at 1:15PM, Informed V2 DON (Director of Nursing) of above observation. V2 said that nurses should keep the medication refrigerator locked and they should mark the date when they opened the medication. Facility's policy on Medication storage revision date 7/2/19 indicated: Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes, and needles. Guidelines: 3. General storage procedures: 3.2 Facility should ensure that all medications and biological, including treatment items are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 5. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened.

Based on interview and record review the facility failed to follow its Transfer policy by failing to provide a two persons assist while transferring a dependent resident from bed to wheelchair. This failure affected one of three residents (R1) reviewed for accidents. This failure resulted in R1 falling from a mechanical lift to the floor and sustaining a fracture of the left superior and inferior pubic rami medially, a sacral fracture and small hematoma. Findings Include: On 2/5/25 at 10:30am, V3 (RN) stated that she provided care to R1 on the day of the fall (2/3/25) and was called to the room by V4 (CNA) after R1 slid out of the sling to the floor during transfer from the bed to the wheelchair. V3 stated that she assessed R1 and noted a cut on the left outer ear. V3 stated that 911 was called and R1 was taken to the hospital for further evaluation. On 2/5/25 at 10:20am, V5 & V9 (CNAs) both stated that R1 is a two person assist with mechanical lift. Both stated that there is a color sticker on each resident's bed which indicates the residents transfer status. V7 (RN) stated that she has provided care to R1. V7 stated that R1 is a two-person mechanical lift transfer. On 2/5/25 at 10:30am, V6 (Private Caretaker) stated that she assisted V4 (Primary CNA) in transferring R1 from bed to wheelchair, she applied the right and left sling onto the right leg and left arm. On 2/5/25 at 11:00am V4 (Primary CNA) stated that R1 requires a mechanical lift with two persons assist. V4 stated that she and V6 (Private Caregiver) applied the sling onto R1. V4 stated that she applied the upper and lower left side of the sling while V6 applied the right side. V4 stated that during the process of moving the mechanical lift the left leg came out and R1 slid out to the floor. V4 stated that this is the first incident with R1 and she has worked for [AGE] years in the facility. V4 stated that she provides care to R1 regularly and receives in-services once a month on mechanical lift transfer. V4 stated that each resident has a color sticker on the head of the bed which let staff know the transfer status of the resident. On 2/5/25 at 11:30am, V2 (Director of Nursing) stated that the investigation is ongoing, and she does not know how the resident fell out of the sling. V2 stated that R1 is a two person transfer with mechanical lift. V2 stated that, a plan of correction is currently ongoing, and all steps are being taken to keep residents safe during mechanical lift transfer. V2 stated that R1 has never fallen in the past, and this is the first fall incident with R1. On 2/6/25 9:25am, V3 (ADON) stated that she has been working in the facility for over [AGE] years and is familiar with R1. V3 stated that R1 is oriented to name and requires a two-person assist. V3 stated that staff can locate the resident's transfer status on the foot or head of the bed, and it is color coded. On 2/6/25 at 12:53pm, V1 (Administrator) stated that R1 is a two-person transfer with a mechanical lift. V2 stated that private caregivers are not allowed to transfer residents in the facility because they are not trained by the facility. V1 stated that he thinks staff did not check to make sure the slings were properly secured to the mechanical S-hooks which resulted in the fall. R1 is a [AGE] year-old female admitted on [DATE] with diagnosis of but not limited to ADULT FAILURE TO THRIVE, SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM, and ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE. R1's care profile reads; Hoyer lift. R1's Fall Incident document reads; Nursing Description: Nurse on duty was called to the room by the CNA. Reported the patient had slid from the side of the sling to the floor during a transfer with the lift. Predisposing Situation Factors. During Transfer R1's Morse fall scale evaluation dated 11/5/24 reads; Category: High Risk for Falling. Score: 61. G- Fall Scoring: High Risk 45 and higher. R1's MDS (Minimum Data Set), section GG-Functional Abilities dated 10/1/24 reads; E. Chair/bed-to-chair transfer: 01. Dependent-Helper does all the efforts. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the residents to complete the activity. R1's care plan dated 11/13/2024 reads, R1 presents with a functional deficit in Bed Mobility related to Physical inactivity. R1 requires use of full body lift for transfer related to activity. Intervention- Full body lift with 2 persons assist for all transfer. Hospital record titled, ED Attending Progress Note dated 2/3/25 reads; XR Hip 2 Views left and Pelvis. 1. Fracture of the left superior and inferior pubic rami medially. 2. CT shows also a left sacral fracture and small hematomas. Facility policy titled: Transfer-Manual Gait Belt and Mechanical Lifts dated 1-19-18. Purpose: To protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents. Responsibility: Licensed Nurse, CNA, Restorative, Therapy. Guidelines: Mechanical lifting device shall be used for any residents needing a two person assist, or who cannot be transferred comfortably . Facility's policies and procedures, census and fall log, were reviewed. No concerns were identified.

Based on observation, interview, and record review the facility failured to ensure no medication was kept at the resident 's bedside without a physician order. The facility also failed to assess a resident for safe medication self-administration. This deficiency affects one (R41) of three residents in the sample of 26 reviewed for Medication safety. Findings include: On 5/22/24 at 10:02AM, Observed R41 sitting on her bed. She is alert and oriented x 3, and able to verbalize her needs to staff. She said her buttocks hurt due to her bed sore. She said the wound care nurse gave her medication to apply to her buttocks for pain. She opened her bedside drawer and showed the surveyor the medicated ointment- Calmoseptine. She also showed the surveyor her other medications kept at bedside such as Bio freeze roll on and artificial tears eye drops. She said that she uses the Bio freeze roll on daily and as needed for her pain on her right shoulder due to her frozen shoulder. She demonstrates how she is having difficulty applying the medication to her right shoulder using her left hand due to limited movement. She added that medications in her drawer are disorganized because she was recently transferred from the 3rd floor to 2nd floor. She said that the staff helped her to transfer her personal belongings. She said the nurses are busy and does not want to bother them. On 5/22/24 at 10:30AM, Informed V3 Assistant Director of Nursing of above observation made. She said that residents are not allowed to keep medication at the bedside without a physician order. She said that a resident who request to keep and take their medications by herself will be assessed for Self-administration medication safety. On 5/22/24 at 3:00PM, Informed V1 Administrator and V2 Director of Nursing (DON) of above concern. V2 DON said that resident medication is not kept at the bedside without a physician order. If a resident request for self-medication administration, the interdisciplinary team (IDT) will assess the resident for safety of medication self-administration. R41 was admitted on [DATE] and readmitted on [DATE] with diagnosis listed in part but not limited to Osteoarthritis. Active physician order sheet does not indicate order for: Calmoseptine ointment, Bio Freeze roll on and artificial eye drops. No order indicates to keep medication at bedside. Care plan indicates she has potential for pain related to diagnosis of Osteoarthritis. She is at risk for alteration in skin integrity. Her care plan does not indicate Self-medication administration at bedside. Facility's policy on Medication Storage revised 7/2/19 indicates: Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes, and needles. Guidelines: 2. Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigeration/freezers of sufficient size to prevent crowding. 13. Bedside Medication Storage: 13.1 Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care team and Facility administration. 13.2 Facility should store bedside medications or biologicals in locked compartment within the resident's room. 13.3 Facility should ensure that only facility representatives and the appropriate resident maintains the keys, access cards, electronic codes or combinations which open the locked compartment. Facility's policy on Self-Administration of Medication procedure indicates: Purpose: to provide procedures for determining if the resident can safely self-administer and store medications in their room. Procedure: 1. Resident who requests to self-administer drugs will be assessed at the time of admission or thereafter, to determine if the practice is safe, based on the results of the Resident Assessment- Self Administration of Medications tool. 2. The assessment results will be discussed with the attending physician and an order obtained to self-administer, if appropriate. 3. Bedside storage of legend (Prescription or non-legend drugs is permitted when the assessment demonstrates the practice is safe. 9. Residents who self-administer shall be monitored at least semi-annually by licensed nursing personnel.

Based on interview and record review, the facility failed to perform a complete assessment and notify physician of the significant change of condition for one of three residents (R330) reviewed for quality of care. Findings include: On 05/22/2024 at 4:00PM during interview with V19 (R330's Family Member), V19 stated that at around 11:00AM on 06/20/2023 while talking on the phone with her brother, her brother noticed that R330 was not responding so V19 instructed her brother to call the nurse. On 05/23/2024 at 12:50PM during interview with V22 (Registered Nurse), V22 stated that R330's complete vital signs were part of the assessment of R330 during change in condition and should have been documented. V22 also stated that she was not aware if the facility practices rapid response, so she did not call for one during R330's emergency change of condition. Rapid Response is when a resident demonstrates signs of imminent clinical deterioration, a team of providers is summoned to the bedside to immediately assess and treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest, or death. On 05/24/2024 at 10:40AM during interview with V2 (Director of Nursing), V2 stated that he expects for nurses to call a rapid response on residents having an emergency change of condition. V2 also stated that he expects the nurses to obtain complete set of vital signs as part of the resident assessment at least after 911 was called during an emergency and to inform the attending physician after the emergency situation has been addressed. On 05/24/2024 at 11:00AM during interview with V23 (Physician), V23 stated that he would want to be informed of the emergency situation that his residents underwent, what was done and what the outcome was after the emergency situation had been addressed. Review of R330's progress notes dated 06/20/2023 did not indicate attempt to obtain complete set of vital signs and the physician being informed or updated of R330's condition. Review of R330's Weights and Vital Signs Summary dated 06/01/2023 - 05/31/2024 indicated last set of vital signs were checked 06/20/2023 at 8:57AM. Review of facility's policy entitled Physician-Family Notification - Change in Condition revised on 11/13/18 indicated the following: Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. Guidelines: The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: (B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); - Life-threatening conditions are such things as a heart attack or stroke. Facility was unable to provide policy on rapid response, vital signs and management of change of condition upon request.

Based on observation, interview, and record the facility failed to obtain a tracheostomy tube size order from physician for a resident with a Tracheostomy tube. The facility also failed to implement oxygen as ordered. This deficiency affects one (R180) of one resident in the sample of 26 reviewed for Respiratory Care. Findings include: On 5/21/24 at 12:19PM, Observed R180 lying on bed with tracheostomy tube connected to oxygen at 6LPM (liters per minute). R180 has audible congestion. V13 RN said that she suctioned R180 earlier at 11:30am. Observed R13 perform tracheostomy and oral suctioning. V13 said that R180 is on 40% FiO2. V13 showed surveyor the tracheostomy tubes available at the bedside- Shiley adult flexible 6CN75H and 8CN85H. Reviewed R180's medical records. R180 wass admitted on [DATE] with diagnosis listed in part but not limited to Acute and Chronic Respiratory failure, Tracheostomy, Traumatic subdural hemorrhage, persistent vegetative state. Active physician order sheet indicates: Trach type (Shiley) Trach size: (). No indication of trach size order. Trach collar with FiO2 35%. (FiO2 is the concentration of oxygen in the gas mixture). Most recent respiratory therapy assessment dated [DATE] but signed on 5/22/24 indicated R180 is on 40% FiO2, no trach size indicated. Care plan indicates R180 has tracheostomy and is at risk for infection and complication. Interventions: Trach collar with 35% FiO2 every shift. On 5/22/24 at 9:22AM, Informed V2 Assistant Director of Nursing (ADON) of above concerns identified. V2 Assistant Director of Nursing said that they should have a tracheostomy tube size order for resident on Tracheostomy. Requested the policy. On 5/22/24 at 3:00PM, Informed V1 Administrator and V2 DON of above concern. V2 DON said that they should have a obtained physician order and documented it in physician order sheet. V2 also said that they should follow physician order for oxygenation and implement the care plan written. V2 said that they have only one resident in the facility with tracheostomy tube. Facility's policy on Tracheostomy Tube Change indicates: Equipment: 1. Appropriate size Trach tube Additional Notes: A. This policy is for routine and PRN (as needed) trach tube change. Check physician orders for appropriate trach tube size. B. Each resident need to have a same size and one downsize trach at bedside for safety purpose. Facility's policy on Oxygen indicates: Purpose: to provide oxygen for therapeutic use Procedure: 1) Verify and understand the physician's order.

Based on interview and record review, the facility failed to ensure a resident at risk for falls was supervised and assisted while in the bathroom for 1 of 4 residents (R1) reviewed for safety in the sample of 7. This failure resulted in R1 being sent to the hospital after sustaining a laceration to his head which required staples. The findings include: R1's Admission Record dated 4/5/24 shows he was admitted to the facility on [DATE]. R1's diagnoses includes, but are not limited to, Parkinson's disease, neurocognitive disorder with Lewy bodies, dementia, left foot drop, and abnormalities of gait and mobility. R1's Minimum Data Set (MDS) dated [DATE] shows R1 has severely impaired cognition and is completely dependent on staff assistance for toileting hygiene, shower/bath, dressing, putting on/taking off footwear, and personal hygiene. R1's care plan initiated on 7/31/23 shows he is at high risk for falls due to generalized weakness and cognitive impairment secondary to dementia and R1 will not sustain minor/serious injury. On 4/5/24 at 10:50 AM, V8, Certified Nursing Assistant (CNA), said he was taking care of R1 (3/25/24) that evening after dinner around 6:30 PM. V8 said he was getting R1 ready for bed and sat R1 on the toilet. V8 said he left R1 to attend to R1's roommate and when he returned to assist R1, R1 had gotten off the toilet and was on the floor in the bathroom with his head bleeding. V8 said R1 needs assistance with everything, he does not walk, he is a fall risk, and he needs to have someone with him when he is in the bathroom. On 4/5/24 at 11:02 AM, V9, Registered Nurse (RN), said he was the nurse when R1 fell (3/25/24). V9 said a CNA came and got him and he went to R1's room. R1 was lying on the floor in his room outside of the bathroom. V9 said R1 was bleeding and had a five-centimeter (cm) laceration to the back, right side of his head. V9 said they called 911 and sent R1 to the hospital. V9 said R1 is a fall risk and is dependent of staff assistance for toileting. V9 said R1 needs to be with a staff member when he is in the bathroom and should not be in the bathroom alone. V9 said he was still in the facility when R1 returned from the hospital. V9 said R1's head laceration was closed with staples. R1's Nurse's Note from 3/25/24 at 6:45 PM shows the CNA observed R1 lying on the floor with noted bleeding over the right occipital area and when the nurse did a skin assessment, a five cm laceration was noted to the right occipital area and abrasions to the right knee. The nurse called the paramedics for emergency transfer to the acute care hospital for further evaluation and management. R1's Nurse's Note from 3/26/24 at 6:33 AM shows R1 returned from the emergency department at 11:10 PM (on 3/25/24) with sutures and staples on his right occipital area. The facility's Long-Term Care Facility & IID-Serious Injury Incident and Communicable Disease Report dated 3/29/24 at 3:00 PM shows R1 had a fall with physical harm or injury on 3/25/24 at 6:30 PM. It also shows staff interviews indicate R1 was assisted to the bathroom whereby he was left sitting on the toilet unattended while the CNA remained outside the bathroom door. When the CNN heard a thud, the CNA returned to find R1 on the floor. R1 was transported to the emergency department via 911 ambulance and later returned to the facility with staples to his head laceration. The facility's Fall Prevention Program Policy (revised 11/21/17) shows, Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet.

Based on interviews and record review, the facility failed to follow their transfer policy. The facility failed to safely transfer a total dependent resident that requires a mechanical lift with 2 person assist, by transferring via stand pivot with one person assist. This affects one resident (R1) of three residents reviewed for safe transfer. This resulted in R1 being hospitalized with a CT scan result of distal tibia periprosthetic fracture and distal fibula fracture. Findings include: Initial Incident Report dated 9/12/23, reads in part: R1 complaint of pain over her right ankle. Noted with anterior swelling and left shin swelling. X-ray done and noted with right ankle mildly displaced fracture of fibula. Left knee with pretibial contusion with uncomplicated Right knee arthroplasty. Investigation initiated. Final report date 9/15/23, reads in part: R1 reported being transferred via stand pivot transfer with onset of pain. Upon receipt of results confirming mildly displaced fracture of fibula R1 was transferred to ER for medical evaluation. admitted with diagnosis of right ankle fracture. Fracture were confirmed via CT of ankle. CNA interviewed and admitted to improper transfer via stand pivot without the use of Hoyer lift as per instructions. CNA aware of transfer instruction and policy. CNA was asked why he did not follow the policy and the instruction for transfer and stated that he thought that he can lift the patient without the use of the machine. CNA stated he made a mistake. CNA terminated. Right Ankle X-ray report dated 9/12/23 shows: impression right ankle x-ray acute to subacute displaced distal fibular fracture. Hospital record reviewed CT scan done on 9/13/23 to compare the x-ray on 9/12/23. CT scan of the right ankle without contrast. Facility record reviewed. Section G (Functional Status) in Minimum Data Set (MDS) dated [DATE] shows: transfer is total dependent with 2 person assist. Care plan initiated on 1/12/23 (R1) requires use of full body lift for transfer related to morbid obesity. Intervention: full body lift with 2 person assist for all transfers. On 10/3/23 at 11:30am, V3 (Restorative Nurse) stated that R1 is a Hoyer lift and two person assist transfer. R1 is alert and oriented x 3. Hoyer is used for safety. R1 needs to have a Hoyer lift machine for transfer. On 10/3/23 at 12:00 PM, V4 (LPN) stated that R1 is totally dependent with transfers and V4 always used the Hoyer Mechanical Lift. R1 was already in bed when R1 reported to me that she was transferred incorrectly by the CNA (V7). R1 also mentioned that R1 told V7 that R1 needs two persons and Hoyer lift transfer. But V7 insisted he could do it. R1 reported to me that she might have twisted her right ankle during the transfer with V7. I assessed the ankle, and it looks swollen, bulging on the anterior side of the ankle. I provided ice pack to reduce the swelling, I talked to V7, and V7 confessed that V7 transferred R1 without Hoyer lift and by himself. I reminded V7 not to do that again, I reported to V2 (DON), and V2 took over the investigation. Initially patient refused the x-ray. R1 decided she wants to get the x-ray done around bedtime and she told me she now is in a lot of pain and she can't sleep and then I was able to convince her to get the x-ray. On 10/4/23 at 10:30AM V2 (DON) I got called by the nurse and the nurse reported that R1 was complaining of pain after transfer. I went to see R1 immediately and R1 was in bed and I asked her what happened. R1 reported that R1 twisted her ankle while transfering and I asked R1 how was R1 transferred and R1 stated that the CNA (V7) just picked R1 up. CNA asked if R1 can stand and R1 replied Yes I can stand for a little bit and that incident happened. V7 was aware that R1's leg was twisted during transfer. CNA reported to the nurse also. There was a Hoyer pad in the wheelchair where R1 was sitting. That alone should have prompted V7 to use a Hoyer. I can do it. I thought I can, just do it faster, and that was the explanation V7 told me. I terminated the CNA same day. On 10/4/23 at 12pm, V8 (Director of Rehab) stated that R1 is total dependent with transfer and needs a Hoyer mechanical lift machine with 2 person assist. It is not safe for R1 to be transferred by one person assist and without the Hoyer Mechanical lift. Transfer-Manual Gait Belt and Mechanical Lift, revision date of 1/19/18, reads in part: In order to protect the safety and well-being of the Staff and Residents, and to promote quality of care, this facility will use Mechanical lifting devices for the lifting and movement of residents. Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. Failure to comply with lifting guidelines may result is disciplinary action as deemed appropriate. Use of gait belt for all physical assist transfer is mandatory.

Based on observation, interview and record review the Facility failed to answer call lights in a timely manner for three Residents (R2, R3 and R4) of four Residents reviewed for call lights in a sample of four. Findings include: Facility Call Light Policy, revised 2/2/2018, was reviewed and documents: the purpose to respond to Residents' requests and needs in a timely and courteous manner; Resident call lights will be answered in a timely manner; all residents that have the availability to use the call light shall have the nurse call light system available at all times and within accessibility to the Resident at the bedside or other reasonable accessible location; all staff should assist in answering the call lights and go into Resident rooms to respond to the call system and promptly cancel the call light when the room is entered; and call bell system defects will be reported promptly to the Maintenance Department for servicing. Facility Concern/Compliment Forms, dated 1/1/23, 1/4/23, 1/6/23, 1/11/23, 2/2/23, 2/7/23, 2/8/23, 2/15/23, 2/20/23, 2/19/23, 3/3/23, 3/16/23 and 3/27/23, document issues with call light response time and malfunctioning call lights. On 5/6/23, from 8:26 am through 8:52 am, R2's call light was activated. R2 resided in an Isolation Room that required Personal Protective Equipment/PPE. On 5/6/23, from 8:26 am through 8:52 am, V5 (Registered Nurse) was sitting at the nursing station within view of the call light and walked down the hallway past R2's room and did not answer or deactivate R2's call light. On 5/6/23, at 8:43 am, V7 (Certified Nursing Assistant/CNA) walked past R2's room and did not answer or deactivate R2's call light. On 5/6/23, at 8:32 am through 8:38 am, V4 (Therapy Assistant) walked past R2's room and did not answer or deactivate R2's call light. On 5/6/23, at 8:46 am, V6 (Licensed Practical Nurse/LPN) walked to R2's hallway from the adjoining hallway and proceeded down the hallway and V6 did not answer or deactivate R2's call light. On 5/6/23, at 10:37 am, R3 (alert and oriented) stated, They do not normally come right away when I press my button, I normally wait about thirty minutes, at best. I do not walk, and I need their help. On 5/6/23, at 10:24 am, R4 (alert and oriented) stated, I am the Resident Council [NAME] President. I have to wait a long time, and I mean like an hour, for my light to be answered because there is no help. At nighttime especially, you can hear a pin drop, because there is no one around. Recently, I did not fall, but they said I fell , but I slid off of the edge of my bed, but I did not get hurt. I was trying to get myself up. On 5/6/23, at 10:48 am, R2 (alert and oriented) stated, My call light was on earlier this morning for about an hour. They do not like coming in here because they do not like to put on gowns and gloves. I called them earlier this morning because I got my breakfast delivered while I was still sleeping, and I needed my oatmeal warmed up and I also needed cleaned up. I generally always have to wait for at least a half hour to an hour for them to answer my light. On 5/6/23, at 12:15 pm, V2 (Director of Nursing) stated, I know we have had issues with call lights, but we have enough staff and there should be no reason that we cannot answer them faster than 30 minutes. I have been in-servicing them and tried to get the issue corrected. No staff should walk past an alarming call light.

Based on interviews and record reviews, the facility failed to implement a fall intervention such as supervision for a resident identified as moderate risk for fall. This affects two residents (R62 and R312) reviewed for fall incident and supervision. This failure resulted in R312 having a fall incident, sustaining a scalp laceration that required a transfer to a local hospital for further evaluation. R312 received 5 sutures on his laceration. Findings Include: On 4/25/23 at 11:00am, observed R62 sitting in the wheelchair, with his head down. R62 up on his wheelchair and position close to foot base of his bed area. Call light attached to side rails of the bed not within reach of R62. Observed falling leaf icon by his name at the door area. R62 has a BIMS score of 9 (8-12 suggests moderately impaired). R62 is care plan for moderate risk for fall related to [NAME] problems, weakness, L4 compression fracture with Kyphoplasty, Arthritis, deaf both ears with revision date of 12/14/22. R62's MORSE Fall Evaluation dated 4/16/23 scored 80.0, which is high risk for falling post fall evaluation. On 12/12/22 MORSE Fall Evaluation scored 40.0, moderate risk for falling. Fall care plan interventions are as follows: be sure the resident call light is within reach and encourage the resident to use it for assistance as needed dated 11/14/2018. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility dated 11/14/2018. Follow Facility fall protocol. R62 is also care planed for ADL: Self-care deficit due to inability to perform activities of daily living independently. Client/resident requires assist of 1 staff with grooming, assist with dressing, assist with toilet use, and assist with bathing (12/14/22). Interventions: Provide assistance with care and set care items within reach, and reinforce safety instructions as needed during care, and try to accommodate client/resident's customary activities as much as possible dated 9/8/22. Facility Reported Incident date 3/19/23 reads in part: R312 sustained a fall from his wheelchair hitting his head on a heater. Staff responded immediately and noted a laceration to the right side on his head. 911 called and R312 transferred to local hospital ER for evaluation. R312 admitted for observation post fall due to anticoagulant use and received stitches but did not provide additional details. Final report dated 3/23/23 CT of head and cervical spine were done with no acute findings. Five sutures were applied to the laceration site. R312 cognitive status is alert and oriented x2 with episode of confusion and forgetfulness. R312 was unable to recall how the fall occurred. R312 propels himself around the unit using his feet. The wheelchair was noted to be behind R312 and unlocked. R312 hospital record dated 3/19/23 reviewed, 1 cm laceration on scalp, received 5 sutures. R312 MORSE Fall evaluation upon admitted d 2/16/23 scored 41 (Moderate Risk for Falling). R312 has a care plan for at risk for falls due generalized weakness, gait balance problems. Unaware of safety needs and use of diuretic dated 2/17/23. R312 section G (Functional Status) in MDS (Minimum Data Set) date 2/23/23 reads in part: Locomotion on unit: how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair: self-performance 3 (Extensive assistance) and Support: 2 (one person physical assist). On 4/27/23 at 11:45am, V29 (RN) stated that R312 up on his wheelchair, roaming the unit. Able to propel. Redirectable at times. R312 is Moderate risk for fall. R312 is in falling leaf program, there is a leaf by the door on his name. We remind R312 to call for assistance. We monitor to try and make sure R312 does not stand up from a wheelchair and remind R312 to sit down on his wheelchair when observed trying to stand up. There is a potential for fall because R312 is moderate risk for fall. Last time I saw R312 during my shift, was right before I attended to another resident. I saw R312 propelling himself toward the nurses station. R312 goes roaming around the unit during my shift, goes in the dining room and at times other residents rooms. On 4/27/23 at 12:00pm, V2 (DON) stated We identified who are fall risk, by leaf by the door, we pay extra attention on resident who are on fall leaf program. We provide supervision. R312 is able to propel himself. When R312 was admitted he is a little hard to take care of. R312 got better during his stay in the facility, more stable and more social with staff. This is R312 norms, R312 would propel himself in and out of the dining room area and in the unit. On 3/19/23 fall incident, Staff were in the nurse's station. We are not supposed to redirect him, it is his norm to be in and out of the dining room, propelling himself on his wheelchair. Staff are not constantly obligated to look at the 20 patients, nurses may turn their heads and talk at the time R312 fell . R312 was in visual distance but they are not looking at R312 at the time of the fall incident. No one witness the fall and staff just heard R312 yelled and made a noise. 911 was called and R312 was sent to the hospital. R312 has laceration on his head and receives 5 sutures in the hospital. On 4/26/23 at 1:30 pm V14 (LPN) stated, Came to work and doing her beginning of shift round, R312 not in his room. On her way back in the nurse's station area, V14 heard staff that there is a resident on the floor. In dining room, noted R312 on the floor inside lying position, I cannot remember which side. Wheelchair behind R312, and wheelchair was not locked. Laceration on top of R312's head, medium bleeding. We put pressure until the 911 paramedic came and took R312. R312 norms is that he goes around the unit, in the wheelchair and propel himself with his feet. High risk for fall and need redirection and supervision. Fall Prevention Program with revision date of 11/21/2017 reads in part: To assure the safety of all residents in the facility, when possible, the program will include measures which determine the individual needs of each resident by assessing the risk for falls and implementation of appropriate intervention to provide necessary supervision and assistive devices are utilized as necessary Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Safety interventions will be implemented for each resident identified at risk. MORSE Fall Scale Evaluation and Falling leaf program dated 6/1/22 reads in part: The facility has instituted Falling Leaf of Program as one intervention of the fall reduction process. With this program the interdisciplinary team targets a select of residents who are at risk for falls. Fall Risk is based upon Fall Risk Factors, and it is more than the total score. Fall Risk factors are determined and target interventions are initiated to reduce falls. Resident who are placed on the Falling Leaf Program may have a falling leaf placed in at least one or more of the following locations as appropriate for visually identify the residents as needing special precautions to avoid falls. The staff will visually check all residents on the program as determined by the team to ensure safety, assist with care needs, and prevent unsafe self-transfers. Staff that identify a resident as needing observations to prevent falls will check to see if the residents is involved in an unsafe action, which could lead to falls the staff member will attempt to determine the resident need such as toileting, pain relief or a change of environment or other need.

Based on observation, interview and record review, the facility failed to implement infection control regarding hand washing when performing incontinence care. The facility failed to disinfect blood pressure equipment and a medication plastic tray in between resident usage. The facility failed to don Personal Protective Equipment (PPE) when entering a contact isolation room. These deficiencies affect five residents (R16, R67, R78, R97 and R212) in the sample of 29 reviewed for Infection control. Findings include: On 4/25/23 at 10:53am, observed R67 has a soiled adult incontinent brief with urine. Observed V6 CNA cleanse R67's buttocks/ peri-area with wet towel. After cleansing using the same gloves, she took skin protectant cream and applied to R67's buttocks/peri area. At 10:56am informed V6 of observation made that she did not remove her gloves and wash her hands after cleansing R67's buttocks /peri area before she applied skin protectant cream. V6 CNA said that she forgot to remove her gloves and wash her hands before she applied the skin protectant to buttocks/peri area. On 4/25/23 at 1:01pm, V7 RN prepared medication for R67 and placed it on a plastic medication tray. V7 entered the room and placed the medication tray on R67's bedside tray table. After administration of medication, V7 did not disinfect/sanitize the plastic medication tray. V7 placed the plastic tray on top of the medication cart. On 4/25/23 at 1:08pm, V7 RN prepared medication for R212 and placed it on the plastic medication tray. V7 entered the room and placed the medication tray on R212's bedside tray table. After administration of medication, V7 did not disinfect/sanitize the plastic medication tray. V7 placed the plastic tray on top of the medication cart. On 4/25/23 at 1:23pm, Informed both V7 RN and V9 RN of above observation. V7 said that she forgot to disinfect the plastic tray in between resident usage. On 4/25/23 at 4:50pm, V12 LPN checked Blood pressure (BP) on left arm of R16 and obtained a reading of 154/74mmhg. V12 did not disinfect/sanitize the BP equipment and placed it on top on medication cart. Then V12 proceeds to R78 and checked R78's BP on his left arm and obtained 107/78mmhg. After V12 was done taking the BP, informed V12 of above observation. V12 said that he forgot to disinfect the BP cuff and tubing in between resident use. On 4/25/23 at 4:14pm, informed V3 ADON of above observation. V3 said that the CNA should wash her hands and don a new pair of gloves before applying the skin protectant to buttocks/peri-area. V3 said that the nurse should disinfected/sanitized the plastic medication tray and BP equipment after using or in between resident use. On 4/26/23 at 3:06pm V21 Infection Preventionist said that CNA should remove gloves and wash hands after providing incontinence care. CNAs should don a new pair of gloves when applying skin protectant to buttocks/peri area. V21 said that the nurse should disinfect/sanitize any equipment use inside the resident room. The nurse should disinfect/sanitize the plastic medication tray and BP equipment in between resident use. Facility's policy on hand hygiene indicates: Hand hygiene means cleaning your hands by using either hand washing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e., alcohol-based hand sanitizer including foam or gel) Guidelines: When to perform hand hygiene (either alcohol based hand sanitizer or handwashing): *After contact with blood, body fluids or excretions, mucous membranes, non-intact skin or wound dressings. 35546 On 4/25/23 at 12:23 PM V14 (LPN-Licensed Practical Nurse) went into R97's room to check for the manual resuscitator. R97 is on contact transmission-based precautions for ESBL (extended-spectrum beta-lactamases) and VRE UTI (vancomycin-resistant enterococci urinary tract infection). There is signage on the door indicating the transmission-based precautions. V14 was wearing a mask and donned gloves before entering the room and checking through the bedside table for the manual resuscitator. V14 did not put on a gown before touching the items and drawers. V14 was asked why she did not put on a gown. V14 said I put on a gown when I do anything to (R97). On 4/26/23 at 3:00 PM V21 (Infection Preventionist) said the staff should do hand hygiene and put on a gown and gloves when going into the room. Policy: Infection Precaution Guidelines Revisions: 1/10/18 Transmission-Based Precautions will be employed for known or suspected infections for which the route of transmission/prevention is known. The transmission-based categories are the following: Airborne, Droplet, Contact. 3. Contact Precautions: In addition to Standard Precautions, use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, such as handling environmental surfaces or resident-care items.

Based on observation and interview, the facility failed to ensure that call lights are functioning in 17 of 98 residents bathrooms (200, 225, 227, 228, 229, 231, 232, 235, 244, 308, 322, 328, 342, 346, 347, and 348) observed for bathroom call lights functioning. Findings Include: On 4/26/2023 at 12:15 PM, R364's family member said that the call light in R364's bath room does not work. On 4/26/2023 at 1230 pm, observation was made with V16 (Certified Nurses Assistance) to check call lights functioning in the resident's bathrooms on second floor west unit. Observation was made that the following residents' bathroom call lights were not functioning (225, 227, 228, 229, 231, 235, and 237). room [ROOM NUMBER] bathroom was the only bathroom with a bell. V16 said that if he is at the nurses' station, he will not be able to hear the bell ring. V16 said that he instructs the residents' to yell out or hit the wall for assistance when they are in the bathroom and need assistance. V16 said that the call lights in the bathrooms have not been working for at least one year. On 4/25/2023 at 11:10 AM, observation was made with V18 (Director of Environmental Services), and V19 (Corporate Director of Environment) for the functioning of bathroom call lights in residents' bathrooms. 17 of 98 residents' (200, 225, 227, 228, 229, 231, 232, 235, 244, 308, 322, 328, 342, 346, 347, 348) bathroom call lights were not functioning, and only one bathroom (225) had a bell for an alternative to call light. Facility Call light Policy: Effective Date: 11-28-12 Department: All Reviewed/Approved by: IDT Revisions: 2-2-18 Purpose: To respond to resident' requests and needs in a timely and courteous manner.

Based on observation, interview, and record review the facility failed to maintain dignity for two residents (R28, R71) of ten reviewed for dining in a sample of 30. Findings include: On 4/25/2023 at 12:10pm V22(Certified Nursing Assistant-CNA) was observed standing while feeding R28. On 4/25/2023 at 12:20pm V22 said I must go to each table to assist with feeding. On 4/27/2023 at 1:00pm V2(Director of Nursing-DON) said all staff while assisting with eating should be at eye level. A care plan dated 4/10/2022 with an intervention of encourage the resident to take time eating and to alternate food with sips of fluids. On 4/25/2023 at 12:15pm V22 was observed standing while feeding R71 lunch. On 4/25/2023 at 12:20pm V22 said I must go to each table to assist with feeding and then sat down. On 4/27/2023 at 1:00pm V2(Director of Nursing-DON) said all staff while assisting with feeding should be at eye level. A care plan with a revision date of 2/13/2023 with an intervention assist resident during mealtime. Facility Policy: Feeding and Assisting Residents to Eat Purpose: To assist the resident to obtain nutrients and hydration. To provide a socializing experience for the resident. Procedure: 3. Assist resident to comfortable position, 60 degrees to 90 degrees. Rationale/Amplification: Nursing personnel assisting should be positioned/seated at eye level with the resident to provide a relaxed and comfortable environment, and to avoid a standing over image.

Based on interview and record review, the facility failed to ensure that a resident was provided with safe care in a manner, considering the resident's history of refusal of care and aggressive behavior toward staff; the resident became aggressive with staff while incontinence care was being provided and the staff member was not familiar with the resident or related interventions for care; the resident then had a fall, and staff proceeded to transfer the resident from the floor to the bed, using a mechanical lift, while the resident continued to be in an agitated state. This failure applied to one (R5) of three residents reviewed for accidents and supervision; and, resulted in R5 having a diagnosis of right femur fracture. Findings include: R5 is a [AGE] year-old female originally admitted to the facility on [DATE]. R5 has medical diagnoses that include unspecified fracture of lower end of right femur, morbid (severe) obesity, [CONDITION(S)] with behavioral disturbance, muscle weakness, repeated falls, and history of falling. R5's current MDS (Minimum Data Set) assessment dated [DATE], documents: Section C (Cognitive Patterns) No - attempt to conduct interview with resident (resident is rarely/never understood) Section G (Functional Status) Bed Mobility - 3. Extensive assistance / 2. One-person physical assist Transfer - 7. Activity occurred only once or twice / 3. Two+ persons physical assist Bathing - 4. Total dependence / 2. One-person physical assist Functional Limitation in Range of Motion - 2. Impairment on both sides / 2. Lower extremity (hip, knee, ankle, foot) Facility provided initial incident report form which documents the following: Reportable Event Occurred on: Date: 7/3/22 Time: 4:45am Reported by: V2 Director of Nursing On 7/3/22 the resident was eased to the floor during a behavioral incident while receiving incontinence care. Upon easing the resident to the floor, the resident's combativeness increased, and she began to kick her legs and swing her arms around. Additional staff were called to the room for support. The resident was immediately assessed by nursing staff. Vitals were attempted but the resident refused. A whole body assessment was also attempted but also refused by the resident despite multiple attempts for education. Limited assessment was able to be done as allowed by the resident. The resident verbalized that she had pain in her right knee upon palpation and movements by the resident. Telehealth evaluation was performed by (V14 Medical Doctor). X-rays were ordered by the physician but refused multiple times by the resident. The resident also refused further examination or interventions by staff. Immobilization of the site was attempted as best as possible with use of pillows and frequent reminders and education on importance of use and compliance was given to the resident. Multiple attempts to provide PRN pain medication were given. She finally agreed to take PRN Tylenol at 10:20 am. Her pain continued to be monitored and PRN medication continued to be offered and administered as needed. She has a long-standing history of refusal of care and lack of cooperation with staff. The nurse practitioner and family were made aware of all matters. Family was asked to come to facility to in education and cooperation of resident for x-ray or further intervention. The resident agreed to have the x-ray taken after multiple attempts from family present in facility. X-ray results returned with results of valgus deformity is noted. Distal femoral acute fracture with impaction. Marked [CONDITION(S)] changes. Osteopenia. After discussion with NP, family, and resident a current do-not-hospitalize order was revoked and an order to send to (local hospital) for evaluation was given. The resident's sister will be present in the facility to aid in compliance with the transfer. Staff will follow up with (local hospital) ER for residents' status. The physician and family were made aware of all matters. Investigation was initiated. 8/14/22 at 1:45pm V17 (CNA) stated, I had just started working at the facility on July 1st and this was my first-time taking care of (R5). I was providing incontinence care. No one ever told me that she was so aggressive. Not until after she fell , then they told me that she is always aggressive with everyone and that when she acts that way, you can't change her, you just have to leave her like that. But that's not right either, to leave her sitting there dirty. She was being very aggressive since I walked in the room. Saying nasty things to me and being extremely rude. She is very aggressive. When she was starting to fall, I went to her side and assisted her down because I can't lift her. I laid her on the floor and put a pillow under her and called the nurse. She was yelling and screaming at everyone the entire time. I don't really know their names because I never worked on that floor again after that night. I just remember one CNA and there were two other nurses, I think. I know that I called for the nurse right away though. When R5 was on the floor, she was kicking and hit the dresser (next to the bed) and scratched her right toe (I believe). She wasn't complaining of pain or anything, the only thing we noticed was the skin tear on her toe from kicking the dresser. She made no complaints of pain while she was on the floor. The nurse assessed her first and then we had to use the mechanical lift to get her off the floor. I told them (other staff in the room), let's use the mechanical lift and they said, how are we going to use the lift? I told them that I have a lot of experience and we can use the lift. When asked how they used the lift with the resident on the floor kicking and screaming, with four people in such a tight space, V17 stated, well, we moved the bed and then used the mechanical lift. While we were using the lift, she was still yelling and being aggressive, the whole time she was being aggressive; she did not calm down until she got on the bed. The other CNA and I managed to get the sling under her and then we used the lift to move her. The nurse was trying to get her to calm down and explain to her that we had to get her on the bed, but she was screaming obscenities and saying that she was going to get us fired. Once she was in the bed, we settled her in, and the nurse checked her again. I think they sent her to the hospital afterwards, I don't know; I haven't worked with her since. V17 then affirmed that none of the nurses or other staff who were familiar with R5 gave her any education or instructions on how to care for R5 even though she has a history of refusing care and being aggressive towards staff; V17 stated that she had no prior knowledge of the type of care/interventions R5 required prior to walking into her room that night. 8/13/22 at 12:42pm, V13 (LPN) stated, I was in the nurse station charting and I heard the CNA yell for help, and I went immediately to investigate. R5 was on the floor and kind of combative, kicking and swinging her arms. I tried to calm her down and re-direct her behavior, but she was already very mad and upset. I observed her on the floor beside her bed and I assessed her. I tried to take her vitals, but she refused. I only remember that she was complaining of pain on the right knee. I offered her a pain pill, but she refused. She was alert x2 at this time and her level of consciousness did not change so I called for help to use the mechanical lift to transfer her back to bed. When she was on the bed, I talked to her and tried to calm her down. I offered her pain medication again and she still refused. I told her I would be back and to press the call light if she needs something. I called the doctor, and he ordered an x-ray, and I called her power of attorney. The pain was new, and she pointed to her right knee. I ordered the x-ray STAT. I think it was done in the morning. It was probably around 4am when the fall occurred. There was nothing unusual about her knee, no swelling or bruising. (R5) was just complaining of the pain and I could see that she could bend it. When she was in the bed, I looked again, and her knee did not look swollen or asymmetrical. I did not suspect any injury or fracture. 8/12/22 at 11:45pm, when asked about R5's fall on 7/3/22, V16 (CNA) stated, yes, I was working but I wasn't assigned to her. I think it was a new CNA (V17 CNA). The nurse called me to help; (R5) was already on the floor. I don't remember exactly who all was there, but it was four of us. We used the mechanical lift and put her back on the bed. V16 accompanied surveyor into the room that R5 was residing in at the time of the fall and demonstrated for surveyor how the resident was found when he entered the room. The bed was near the window/wall/AC side of the room and in between the bed and A/C unit, there was a dresser at the head of the bed approximately two feet wide. Per V16, R5 was on the floor, in between the bed and the AC unit, (directionally) her head was at the foot of the bed and her feet were toward the top of the bed, so she was able to kick the dresser that was next to the bed. Surveyor asked how four people and a mechanical lift were able to safely transfer the resident, who is obese, in such a tight space. V16 replied that they moved the bed over and then transferred the resident. 8/13/22 at 4:32pm, V18 (RN) confirmed being the oncoming nurse after R5's fall. Per V18, after multiple refusals, R5's family came to the facility and convinced the resident to get the x-ray and eventually go to the hospital. V18 affirmed being very familiar with R5 and stated, (R5) doesn't like me so she always refuses medication or that I provide any care for her. If she likes you, she will get along better, but mostly she just refuses everything. V18 stated that since the fracture was confirmed with the x-ray in the facility, R5 was given narcotic pain medication in preparation for transfer to the hospital since it was expected that she would have pain with movement/transferring. When asked about transferring a resident after a fall, V18 stated, before you move the patient you have to assess range of motion and ask if they hit their head and assess for any obvious injuries. If there is acute pain, then I would call the physician and ask for an x-ray. If a patient has a fall and then complains of pain with movement, I would not transfer them (using mechanical lift). I would call the physician and then 911 to send them to the hospital. Nursing Progress Note dated 7/3/22 06:24 written by V13 (LPN) reads: Writer was told by the CNA that resident was on the floor assisted by CNA. Writer went to the resident's room and noticed resident lying flat and both legs extended on the floor. Resident was alert and responsive, oriented x2. No changed in level of consciousness. Assessment done on both upper and lower extremities. Complained of pain on right knee when touched and during movements. Writer called on call Dr. and asked for Xray on right knee and Neuro check. Writer texted (named facility management) and made aware of the incident as well. Telehealth Evaluation (written by V14 Medical Doctor) Effective Date 7/3/2022 4:53AM Primary Chief Complaint: Fall with injury .C/O right knee pain .Review of systems (includes) MS/extremities: Pos for injury, R knee pain .MSK: lim range of motion, R knee tenderness .Diagnosis, Assessment/Plan (TE): A: R knee pain P: R knee xray - Pain in right knee (Primary) Orders: R knee xray Neuro checks Notify THE of any change in condition. Disposition: Stay at Facility. Nursing Progress Note dated 7/3/2022 13:55, written by V12 (LPN) reads: Received resident in bed sleeping in bed in no apparent distress. Upon medication pass at 8:30AM resident complained of pain in her right knee. She was unable to quantify her pain or provide further description. She was noted guarding her lower extremity. No other indicators of pain. Writer attempted to check her vitals, but the resident refused. No range of motion was attempted. The resident was instructed not to move her extremity any further and her leg was immobilized with the use of pillow. The resident was offered PRN Tylenol but refused it. Nursing Progress Note dated 7/3/2022 23:07, written by V15 (RN) reads: At 10:00pm, called (x-ray company) to f/u x-ray of right knee results, impression: valgus deformity is noted. Distal femoral acute fracture with impaction. Marked [CONDITION(S)] changes. Osteopenia. Informed POA about the x-ray results, both in agreement to send resident to the hospital for evaluation. Called ambulance (company) at 10:30pm .ETA in 1-2 hours. PRN [MEDICATION(S)] given at 10:00 pm for pain. Right leg immobilized with pillow. (Relative) returned to the facility at 11:00pm, she will accompany resident to the hospital. Review of R5's medical record includes multiple progress notes and documentation of resident long history of refusing care and aggressive behaviors towards staff with no indication of improvement or change in behavior. R5 current care plans include the following focus areas: Behavior Symptoms (R5) displays aggressive and agitated behavioral symptoms. These behavioral symptoms are manifested by resisting direct care and refusing any physicians to assess her. (R5) refuses assistance for basic care such as taking showers, taking medications, basic hygiene, and meals. Staff continue to educate and redirect her on the importance of complying with care. However, she continues to be non-compliant. (R5) will be verbally aggressive and hostile towards staff when care is being rendered or when staff visit her to address her needs. Date Initiated: 10/02/2020 Revision on: 07/25/2022 Interventions include (but not limited to): If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again .Provide resident with opportunities for choice during care provision. Date Initiated: 10/02/2020 Revision on: 10/02/2020 (R5) will often times become upset and/or agitated with staff. Staff reports that she can be verbally aggressive daily when care is being rendered. She is noted to yell, scream and/or curse at staff. Often, it can be difficult to redirect her. When staff will ask her questions, she will often tell staff to leave her alone. Psych consult is being recommended for mood and behavioral management. Resident has a hx to refuse psychiatry consults, medications, and treatments. Staff to continue to offer support, redirect, and educate as needed. Date Initiated: 09/01/2021 Revision on: 09/01/2021 Interventions include (but not limited to): Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: 09/01/2021 Created on: 09/01/2021 Behaviors - Refusal (R5) will refuse to be weighed, take medications, and follow treatment orders. When staff attempt to redirect and educate on the importance of adhering to care recommendations and orders, she will yell, scream and/or curse at staff. It can be difficult to redirect resident. Staff are to continue to redirect, offer support, and educate. Date Initiated: 06/07/2022 Created on: 06/07/2022 Interventions include (but not limited to): Anticipate and meet the resident's needs. Date Initiated: 06/07/2022 Created on: 06/07/2022 (R5) has potential impairment to skin integrity r/t history of healed sacral stage 3 pressure wound and healed deep tissue injury right posterior achilles due to fall at home and suffered an avulsion fracture to her right calcaneus, [CONDITION(S)], C. Diff and OSA. Date Initiated: 07/08/2022 Created on: 03/26/2022 Revision on: 07/08/2022 Interventions include (but not limited to): Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Date Initiated: 03/09/2022 Created on: 03/26/2022 During the course of this survey, reviewed current care plan documents for R5 (36 pages) and there was no inclusion of interventions for how to safely transfer the resident (i.e., from bed to wheelchair, etc.). 8/13/22 at 5:30pm, V2 (Director of Nursing) stated, (R5) hit her leg with the side of the table when she fell because she was kicking and screaming with a behavior. (After the fall) R5 was transferred with the mechanical lift and then was complaining of pain in her knee. She went to the hospital after many refusals with her sister. We were able to do the x-ray and then the sister was able to convince her to go to the hospital. If the patient fell on the floor, we send them to the hospital if we suspect major injury or fracture, if so, we don't move them, we immobilize .if we are able to safely transfer back to the bed we do. If there is pain with movement, I would not assume that is related to a fracture - but it would be an indication for an x-ray if it's new pain. When she was in bed she started complaining of the pain in her knee; she did not complain of pain until she was in the bed. The nurse had to clear the commotion around her first and then they transferred her back, but she didn't start complaining of pain until she was on the bed. Surveyor asked V2 if it seemed safe to transfer the resident using a mechanical lift if the resident was agitated and/or complaining of pain. V2 responded, I would still do the transfer with a mechanical lift if it was leg or arm pain. When she was kicking the dresser, it was with her upper shin. I don't think they transferred her while she was agitated .It would probably be safer not to touch her. If I was the nurse on the floor, it would be better to call 911 .I don't think she has a history of falls. V2 confirmed that this information was based on staff reports provided, as he did not personally witness the events related to R5's fall. Facility document titled, Fall Prevention Program (Effective Date: 11/28/12 and Revisions: 11/21/27) reads: Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness .Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan .This policy is a guideline only. Each resident has his or her own set of circumstances which may require that this policy not be followed. The needs of each resident supersede this policy.

Based on interviews and record reviews, the facility failed to implement orders from an authorized practitioner related to a urine test for one (R4) of three residents reviewed for quality of care. This deficiency resulted in R4 being sent out to a local emergency room secondary to back pain and status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R4 is an [AGE] year-old female, admitted in the facility on 09/08/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to R4's progress notes, the following were documented in part but not limited to the following: 11/19/2021: R4 was observed to be confused and disoriented. The progress notes also read: Will endorse to monitor mentation. No urinary frequency, no complaints of dysuria noted during shift. Oral fluids encouraged. 11/24/2021: CBC (complete blood count) with differential and Platelets results relayed to V8 (Nurse Practitioner), ordered UA (urinalysis) C/S (culture and sensitivity). 11/30/2021 time stamped 4:15 AM: At 4 AM, R4 was found sitting on the floor, no bruise or injury noted, asked what happened, she said, I don't know, I fell , denies pain and denies hitting head, alert and confused. 11/30/2021 time stamped 12:56 PM: R4 had fallen out of her bed. Noted to be laying down on the floor next to the bed. Alert, oriented x 1 (meaning awareness to reality at the moment), able to answer simple questions. R4 was transferred out to the emergency room for further evaluation and management as ordered. Progress notes dated 11/30/2021 time stamped 2:52 PM indicated that R4 will be admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per R4's hospital records' discharge summary notes dated 12/08/2021 reads: Detailed hospitalization Summary: Has history of humeral neck fracture from previous fall, who presents after unwitnessed fall, found to have [CONDITION(S)] (urinary tract infection). Acute urinary retention, Leukocytosis, Acute [MEDICATION(S)] without Hematuria, E - coli (Escherichia coli) on admission, Acute Metabolic [CONDITION(S)] due to above. R4's hospital's laboratory result for urine culture dated 11/30/3021 indicated abnormal; Escherichia coli of greater than 100,000 cfu/ml (colony forming unit). During review of R4's medical records in the facility, there was no result found regarding UA C/S test or an order from physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 06/15/2022 at 12:20 PM, V2 (Director of Nursing) was asked regarding R4' urine test. V2 stated, On R4, I called laboratory but no urinalysis culture and sensitivity test was found on 11/24/2022. It was in the progress notes that UA C/S was ordered. I don't have any explanation as to what happened. Based on her labs on 11/24/22, her WBC (white blood count) was 12.59, which was high so UA C/S was ordered but I cannot find any documentation of the result. Laboratory test dated 11/24/2021 indicated that R4's WBC (white blood cell) count was 12.59. Normal count is 4.80 to 10.80. V8 (Nurse Practitioner) was also asked on 06/15/2022 at 2:29 PM regarding R4. V8 replied, If it was written in the progress notes, most likely I ordered for a UA C/S. I can't recall if a result was relayed to me. I expect staff that orders should be carried out and should be relayed to me. UA C/S is one part of the spectrum in treating [CONDITION(S)]. Nurses must notify me of any unusual changes so I can check and be able to make some orders. The UA C/S is a component of a larger picture in identifying possible infections and among other things with R4. On 06/16/2022 at 1:10 PM, V15 Licensed Practical Nurse (LPN) was asked regarding R4 and for orders related to laboratory test. V15 replied, For verbal orders or telephone orders, I enter it to eMAR (electronic medication administration record) and for laboratory test, we make a requisition form and make the necessary endorsements. Laboratory technician comes to the facility every day in the morning. If it's a STAT (immediately) order, we call them, and it is done right away. If its UA C/S, will ask physician for straight catheterization if needed or if resident can go to the bathroom to take the specimen. Most of the time, R4 goes to the bathroom with assistance. She urinates in the bathroom. If there is an order from nurse practitioners or medical doctors, it should be carried out. A follow- up interview with V2 was conducted on 06/16/2022 at 11:40 AM regarding R4's hospitalization . V2 verbalized, On that day of 11/30/2021, she was sent out after a fall incident and complained of pain in the back. She was admitted in the hospital and was diagnosed with AMS and [CONDITION(S)]. I believe she runs high WBC and not sure of colonization. On 11/19/21, she was having more confusion and disoriented. The nurse made an assessment, and she was assessed for signs and symptoms of [CONDITION(S)] but none and determined that it was her baseline. She had a blood draw on 11/22/21 and on 11/24/21. The result of the WBC on 11/24/21 was 12.59, meaning could be an indication of infection or could be her normal. So, a UA C/S was ordered to double check for any possible infection. It was not carried out. For R4, when the nurse received a telephone or verbal order, they must put it into electronic record as an order and they have to write a laboratory requisition. But it was not done. It should be done, if a doctor gives an order, it should be carried out. V14 (Primary Physician) was also interviewed on 06/16/2022 at 12:41 PM regarding R4. V14 replied, I have been taking care of her for quite some time now. She has Dementia, has some occasional confusion, she can verbalize her needs; hard of hearing but able to follow commands and answer questions. I am not sure why the urine was not collected if it was ordered. The order should be carried out. Facility's policy titled Verbal Order revised date February 2014, stated in part but not limited to the following: Policy Statement,Verbal orders shall only be given in an emergency or when the Attending Physician is not immediately available to write or sign the order.Policy Interpretation and implementation: 4. The individual receiving the verbal order must write it on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .o. (telephone order). V2 stated that facility does not have any policy regarding following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview and record review the facility failed to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to follow their Low Air Loss Mattress Use Policy by using multiple layers of linen. These failures include 4 of 4 (R1-R4) residents reviewed for pressure ulcer prevention and treatment. This failure resulted in R1 being admitted on [DATE] with redness on sacral area that subsequently worsened to an open stage 3 pressure ulcer. Findings include: R1 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was started on wound care treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .) R1's July 2021 Treatment Administration Record (TAR) indicates no treatment was done. On 11/17/21 at 10:31am, V11 Registered Nurse (RN) said that she has taken care of R1. V11 RN said that V9 Wound Care Nurse (WCN) does the wound care treatment to all residents. V11 RN, reviewing from R1's progress notes said that R1 was admitted on [DATE] with redness on sacral area. V9 WCN does the weekly skin assessment. V9 WCN did a wound assessment indicating a Stage 3 pressure ulcer on sacral area measuring 0.4x0.4x0.3cm on 7/27/21. Both V11 RN and V10 Certified Nurse's Aide (CNA) said that R1 likes to stay in bed. R1 will be up for therapy and lunch but will request to be put back to bed after due to shakiness and dizziness. On 11/17/21 at 1:02pm, review R1's medical record with V4 Assistant Director of Nursing (ADON.) V4 ADON said that R1 came in with redness on sacral area as documented by V19 Registered Nurse (RN.) V19 RN is no longer working in the facility. V4 ADON said that upon admission, resident will be assessed by V9 WCN. If V9 WCN is not available, she (V4) will do the skin assessment in progress notes. V9 WCN also does the weekly skin assessment. V4 ADON said that they don't do daily skin assessment. V4 ADON said that on 7/22/21, she did a skin assessment on R1. V4 ADON documented noted open sacral area appears like unstageable wound, wound bed 50% slough and 50% reddened, no active drainage. [MEDICATION(S)] dressing applied, R1 agreed for wound physician consult. Air mattress was ordered, heel foam boots and wheelchair cushion provided. Called and left message to V18 Family member. V4 said that she called V20 Nurse Practitioner (NP) for wound care orders. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V4 ADON said for some reason she forgot to carry it out in POS and TAR. V4 ADON said that they don't need to have order for low air loss (LAL) mattress, heel foam boots and wheelchair cushion. V4 ADON said that R1 refused to get up and preferred to stay in bed. Review of R1's care plan with V4 ADON indicated no behavior documented that she refused to get out of bed nor documentation in progress notes. On 11/18/21 at 9:59am, V3 Director of Nursing (DON) said that V9 was on vacation between the 7/21 and 7/26/21. V4 ADON does the wound assessment, and the nurses do the wound dressing while V9 WCN was on vacation. On 11/18/21 at 10:42am, Reviewed Facility's policy on Pressure ulcer/injury risk assessment with V3 DON indicates c. if a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. V3 DON said that V4 did not initiate wound assessment form because this is not new identified wound. V3 DON said that V19 RN who admitted R1 documented it incorrectly. V19 RN is no longer working in the facility and cannot be interviewed. V3 DON said that they don't need to have physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review Facility's LAL mattress policy with V3 DON indicates 1. Verify the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/18/21 at 12:08pm, V3 DON said that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 DON said that R1 has not been seen by her Primary Care Physician (PCP) during her stay in the facility. R1 was only seen by V20 NP. V3 DON said that the resident should be seen by PCP within 72 hours upon admission then every 90 days. On 11/18/21 at 12:17pm, V9 WCN said that she was on vacation when R1 was admitted . V9 WCN said that she saw R1 on 7/27/21. V9 WCN observed R1 with Stage 3 pressure ulcer, she cannot recall what treatment R1 was on. V9 WCN said that she does the wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's POS with V9 WCN showed no treatment order was placed on R1 since admission. Not until she was seen by V21 WCNP on 7/28/21. On 11/18/21 at 12:29pm, V20 NP said that he saw R1 on 7/22/21 and documented that R1 had a stage 3 pressure ulcer per nursing report on his assessment. V20 NP said that he did not see R1's sacral pressure ulcer. V20 NP said that he did not document plan treatment nor plan of care because he expects the nursing and the wound care to document. V20 NP was not aware that R1 did not receive treatment until seen by V21 WCNP on 7/28/21. V20 NP said that he is only aware of what is stated in the record. On 11/18/21 at 12:50pm, V21 WCNP said that she saw R1 initially on 7/28/21 with stage 3 pressure ulcer on sacrum with slough formation and necrotic tissues. Per nursing staff, R1 likes to stay in bed. R1 was seen on a weekly basis from 7/28/21 to 9/29/21. Debridement was also done on sacrum. V21 WCNP said that wound could get worse from redness to stage 3 if no treatment was being done, no off loading, and lying supine for a long period of time. Also, if there is damage to the underlying skin that is not visible or has not come to the surface; the wound can develop fast if the resident has a compromise condition- such as elderly, light weight, paper skin and other underlying conditions. The wound could get worse overnight depending on how compromised the resident is. On 11/18/21 at 2:45pm, V3 DON said that treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's skin report indicated that she has a reopened stage 3 wound to the sacrum on 10/21/21. On 11/17/21 at 10:03am, Observed R2 in lying in bed on a Low Air Loss (LAL) mattress. R2 is alert and oriented x3 and able to verbalize needs to staff. V9 WCN prepares wound supplies for R2 (wet the gauze with NSS, place [MEDICATION(S)] ointment on plastic med cup and removed the foam gauze from individual wrap) and placed them on top of the treatment cart without using liner or tray. Then V9 WCN donned gloves and took the wound supplies inside the room and placed them on top of the bedside tray table without liner or disposable tray next to R2's personal items. V9 performed wound care to the sacrum. V9 used the same pair of gloves in cleansing the wound and applying treatment and dressing. R2 has a flat sheet linen, quilted cloth pad and is wearing a disposable adult brief. V9 said that it is okay to use a flat sheet and cloth pad on R2 while on LAL mattress. R3 was readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's skin report dated 10/13/21 indicated that they have a Stage 4 on left heel, Stage 3 on left gluteal and Stage 2 on right gluteal. On 10/17/21 at 10:15am, Observed R3 lying in bed on a Low Air Loss (LAL) mattress. R3 is alert and oriented x3, able to verbalize needs to staff. V9 WCN prepares wound supplies for R3 (wet the gauze with NSS, place [MEDICATION(S)] ointment on plastic med cup, took small amount of hydrogel placed on top of non-adhesive dressing and gauze) and placed it on top of the treatment cart without using liner or tray. Then donned gloves and took the wound supplies inside the room and placed them on top of the bedside tray table without liner or disposable tray next to R3's personal items. V9 WCN used the same pair of gloves in cleansing sacral area with wet wash cloth and applying treatment and dressing. R3 has flat sheet linen, quilted cloth pad and is wearing a disposable adult brief. V9 said that for LAL mattress, it is okay to use a flat sheet and cloth pad. On 11/17/21 at 1:02pm, Informed V4 ADON of wound care observation with V9 WCN to R2 and R3. Concerns identified in infection control and use of multilayers linen over LAL mattress. V4 said that disposable tray is used to put the wound supplies in a resident room to avoid contamination and ensure infection control. Gloves should be changed after cleansing wound and before handling clean dressing. They only use 1 flat sheet over the LAL mattress. V4 said she already in-service the staff but will re-enforce it. R4 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's skin report upon admission indicated that she has Stage 3 on coccyx and right ischial. On 11/17/21 at 2:12pm, Observed V9 WCN perform wound care to R4. R4 has flat sheet linen, cloth pad and is wearing a disposable adult brief. V9 WCN said that she is not sure of how many layers they can put on top of the LAL mattress. V9 WCN said she will check with V4 ADON because she usually orders the LAL mattress. On 11/17/21 at 2:30pm, V11 RN said that she is not sure how many linens are allowed on top of LAL mattress. Surveyor is referred to V9 WCN or V4 ADON. Facility's policy on Prevention of Pressure Ulcer/Injuries indicates: Purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Risk Assessment: 4. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. Monitoring: 1. Evaluate, report and document potential changes in the skin 2. Review the interventions and strategies for effectiveness on an ongoing basis. Facility's policy on Pressure Ulcer/Injury risk assessment indicates: Purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries. General guidelines: 3. Once the assessment is conducted and risk factors are identified and characterized, a resident centered care plan can be created to address the modifiable risks for pressure ulcers/injuries. Steps in the procedure: 4. C. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. 5. Develop the resident centered care plan and interventions based on the risk factors identified in the assessment, the condition of the skin, the resident's overall clinical condition and the resident's stated wishes and goals. Documentation: 4. The condition of resident's skin Facility's policy on Low Air Loss Mattress indicates: Purposes: a. be able to maintain or promote adequate circulation for resident that are high risk for skin breakdown to those residents that spends most of the time on bed due to medical condition. c. aid in healing of stage 3 or 4 pressure ulcers d. and to prevent the development of pressure ulcer. Procedure: 1. Verify the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 11. As much as possible, use only 1 linen sheet covering the air mattress. Facility's policy on Hand Hygiene indicates: General: cleansing your hands by using either handwashing, antiseptic hand wash, antiseptic hand rub or surgical hand antisepsis. Cleansing your hands reduces: the spread of potentially deadly germs to patients. 5 moments for hand hygiene: 1. Before touching a patient 2. Before clean/aseptic procedure 3. After body fluid exposure risk 4. After touching a patient 5. After touching patient surroundings Facility's policy on Medication Orders indicates: Purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Supervision by a Physician: 1. Each resident must be under the care of licensed Physician authorized to practice medicine in this state and must be seen by the physician at least every 60 days. 3. Orders must be written and maintained in the medical record. Recording orders: 6. Treatment orders- when recording treatment orders, specify the treatment, frequency and duration of the treatment.

Based on observation, interview and record review, the facility failed to ensure that a resident received care and treatment to prevent the development of penile trauma from the use of an indwelling urinary catheter. The facility also failed to clean a resident's genital area after an incontinent episode in a manner that would prevent the potential development of infection and to maintain hygiene. This applies to 2 of 12 residents (R8, R4) reviewed for indwelling urinary catheter and incontinence care in the sample of 14. This failure resulted in R8 sustaining penile trauma, including erosion of the meatus thru the glans to the proximal shaft of R8's penis. The findings include: On February 1, 2016 at 2:10 PM, R8 was in his room, sitting in a wheelchair. A strong urine odor was present. R8 said, I have a catheter strapped to my leg. Sometimes it pulls on my penis. On February 2, 2016 at 8:35 AM, E11 (CNA-Certified Nursing Assistant) was requested to remove R8's incontinence brief and expose R8's indwelling catheter. E11 washed his hands and donned clean gloves and assisted R8 to a standing position before removing R8's incontinence brief to expose R8's genital area and upper legs. R8 had a urinary leg bag attached to his left upper leg with two elastic straps. An anchoring device for the indwelling catheter was located on R8's upper leg, above the urinary leg bag. The urinary leg bag contained clear, yellow urine. It was observed that the urinary catheter had eroded through the tip of R8's penis and now exited from the underside of R8's penis. E11 said, I empty the leg bag twice a shift. The facility's POS (Physician order [REDACTED]. The facility's MDS (Minimum Data Set) dated December 15, 2015 showed R8 was readmitted to the facility on [DATE] and R8 is moderately cognitively impaired, and needs extensive assistance with hygiene, bathing and toileting, frequently incontinent of stool, and has an indwelling urinary catheter. The facility's POS (Physician order [REDACTED]. The facility's Care Plan Activity Report for R8 showed: Effective: September 25, 2015 - (Indwelling) Catheter - Resident at risk for urine infection due to (Indwelling) catheter related to [MEDICAL CONDITION]. Interventions: (Indwelling) catheter care rendered every shift. (Indwelling) catheter changed monthly. The facility's care plan lacked interventions for anchoring the indwelling catheter to prevent pulling and trauma to R8's penis. The facility's nursing admission nursing assessment dated [DATE] showed R8 had an indwelling urinary catheter, draining clear, yellow to amber urine. Records from the local hospital showed R8's indwelling catheter was placed in the Emergency Department on July 19, 2015. The facility's nursing progress note for R8 dated September 18, 2015 at 7:19 PM showed: Noted minimal fresh blood on R8's tip of penis. No complaint of pain on penile area as per patient. Informed physician and ordered to apply antibiotic to penile tip twice a day. Ordered carried out. The facility's nursing progress note dated November 9, 2015 at 9:26 PM showed: At around 6:00 PM, CNA noted laceration/trauma on R8's dorsal part of penis, with minimal bleeding and foul smell. Z1 (NP-Nurse Practitioner) called and ordered antibiotic ointment to site twice a day and R8 for wound consult; orders carried out. On November 18, 2015 at 1:54 PM nursing progress notes showed .Noted more opening around urethra/penile from indwelling urinary catheter. Z1's (NP) progress note dated November 11, 2015 showed Antibiotic ointment to penis laceration. Z1's (NP) progress notes dated November 20, 2015 showed, Penile wound/trauma secondary to indwelling catheter. Continue present management, apply antibiotic ointment to penile wound twice a day, monitor. Z3's (MD) progress note dated November 23, 2015 at 6:15 PM showed Indwelling urinary catheter induced tear to penis. On November 23, 2015, R8 was seen by Z2 (MD-Urologist) outside the facility. Z2's progress note showed: Indwelling catheter with erosion of meatus thru the glans to proximal shaft. Impression: Needs better support of catheter to keep tension off it. On February 3, 2016 at 11:30 AM, E2 (DON-Director of Nursing) said the TAR (Treatment Administration Record) shows daily catheter care for R8. The documentation is signed off by the resident's nurse, however, it is the CNA who provides the catheter care, not the nurse. On February 3, 2016 at 2:45 PM, Z3 (MD) said, R8 was seen by Z2 for damage/trauma to his penis. The urinary catheter should be changed every 4 to 6 weeks. The damage to R8's penis was caused by improper anchoring of R8's indwelling urinary catheter. The problem was related to anchoring the catheter too short, so movement caused trauma to the penile meatus. Anchoring the catheter properly would have prevented permanent injury to R8's penis. On February 4, 2016 at 10:05 AM, E2 (DON) said, It has not been the facility's practice to use an anchoring device for indwelling urinary catheters. The catheters were not being anchored. The facility's undated policy entitled Indwelling Catheter Policy lacked procedures for anchoring the indwelling catheter. The facility's undated policy entitled Urinary Leg Drainage Bags lacked procedures for anchoring the indwelling catheter. 2. R4 has multiple [DIAGNOSES REDACTED]. R4's records showed that the resident had a history of [REDACTED]. R4's quarterly MDS (Minimum Data Set) dated November 6, 2015 showed that the resident is moderately impaired with cognition. The same MDS shows that R4 is always incontinent of bowel and bladder functions and would require extensive assistance from staff with regards to personal hygiene and toilet use. On February 2, 2016 at 10:40 AM, E8 (CNA/Certified Nursing Assistant) assisted E7 (CNA) during R4's incontinent care. R4 was awake and was transferred from high back reclining chair to bed. E7 and E8 removed R4's incontinent brief and pants. R4's incontinent brief was soiled with stool and urine. E8 with her gloved hand used a wet wash cloth with shampoo and body wash solution to wipe R4's pubic area down towards the perineum, including the bilateral groin. E8 used the same wash cloth to wipe R4's perineal area (wiping from the pubic area down towards the perineum, including the bilateral groin then back) three times without changing and/or folding the wash cloth to use the clean side. E7 and E8 then turned R4 to her left side. E8, using the same wash cloth that she used to wipe R4's perineal area, wiped R4's rectal and buttocks area, three times. E8 repeated the same procedure, using another wet wash cloth (warm water only) to rinse R4, then used another dry wash cloth to dry the area. During this observation, E8 did not separate the labia to clean the area to ensure that urine and feces are removed. In an interview held on February 4, 2016 at 10:03 AM, E2 (Director of Nursing) stated that for female residents, the staff should separate the labia and the perineal skinfolds to thoroughly clean the area and to prevent potential infection. E2 also stated that a clean wash cloth or the clean side of the wash cloth should be used to wipe the resident's perineal area to prevent potential infection. The facility's perineal care policy and procedure dated 2002 showed in-part that the purpose of the procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritations. The same policy showed that for female residents, Wash perineal area, wiping from front to back. Separate labia and wash area downward from front to back. Continue to wash the perineum moving outward to and including thighs, alternating from side to side, and using downward [MEDICAL CONDITION]. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth.

Based on record review and interview the facility failed to keep one resident (R1,) out of three residents reviewed for abuse, free from verbal abuse. The facility was notified of an incident of verbal abuse by Z1 (private duty care giver) to R1, yet allowed Z1 to work for three additional days exposing R1 to possible further abuse. Findings include: R1 is a [AGE] year old female with a [DIAGNOSES REDACTED]. The facility's incident report dated 1/4/13 documents that an employee over heard a caregiver telling R1 that she is stupid on two separate occasions. The facility's investigation included a typed statement by E2 (Assistant Administrator) documenting that E4 (transporter) informed him that he over heard the caregiver stating to R1 "how old are you? You are not three years old. You're giving me a headache. I'm getting tired of this." The statement also documented that the caregiver was yelling at R1, and speaking in a very high tone that was very degrading. On 1/10/13 at 4:35pm, E2 stated that he completed the investigation into the situation, and identified Z1 (caregiver) as the alleged abuser. E2 stated that Z1 was hired by R1's family. The facility's guest sign in logs documented that Z1 was at the facility on 1/4/13, 1/7/13, and 1/8/13. E2 stated that 1/8/13 (4 days after the allegation) was Z1's last day working at the facility. E2 stated he did not interview nurses and certified nursing assistants that work directly with R1. On 1/11/13 at 11:02am, E1 (Administrator) stated the reason the facility has released Z1 from caring for R1 is because a supervisor from the Department of Public Health called and questioned her about the incident. When asked if an employee was accused of abuse, what would the facility do? E1 stated " investigate immediately. " When asked what if a caregiver was accused of abuse? E1 stated " I don't train the care giver." E1 was asked how the facility protects the resident. E1 replied "staff would be removed " but "a caregiver would receive supervision." On 1/11/13 at 11:39am, E4 (transporter) stated that on 1/3/13, Z1 had stated to R1 "how old are you?" E4 then stated that on 1/4/13 after therapy R1 was waiting to be transported to her room. E4 added that Z1 stated to R1 "You're driving me crazy. You're not a little kid. You're giving me a headache." E4 also stated that Z1 started complaining to another visitor "she doesn't want to cooperate. I'm going crazy. She's always doing this to me." According to E4, R1 was visibly upset and started fighting him as he tried assisting her. E4 stated that R1 was fighting because she was agitated. E4 added that R1 is normally cooperative when spoken to in a "normal" tone. E4 stated that Z1 continued speaking to R1 in an abusive tone and he was then able to "put two and two together." E4 stated he reported the incident to the E6 (Social Worker). E4 concluded that the facility's policy to protect the resident upon an abuse allegation is to remove the abuser. On 1/11/13 at 11:54am, E6 (Social Worker) stated that she reported to E2 (Assistant Administrator) that Z1 verbally abused R1. E6 added that Z1 stated she was stressed out and its difficult caring for someone with dementia who can't walk. E6 stated that at that time she informed Z1 that her actions constituted verbal abuse. E6 also stated that when she entered R1's room, R1 said to her "someone told me I was a child and I couldn't do it." When asked how would the facility protect the resident in this case? E6 stated "If something like this happen again, we will make sure they are not in our building." On 1/11/13 at 1:25pm, E5 (Licensed Practical Nurse/LPN) stated that since 1/4/13 she has worked with R1 on at least two separate occasions. E5 stated that she entered the room approximately 3 or 4 times during the day to administer R1's medication. E5 stated "there was no one else in the room with R1, just Z1". When asked what was the facility's policy for an allegation of abuse? E5 replied "staff is sent out of the facility upon the complaint and then Z1 investigates." In relation to the abuser being a caregiver, E5 stated "they still have to be separated ". On 1/11/13 at 1:44pm, E7 (Rehabilitation Director, Registered Nurse/RN) stated that when there's an allegation of abuse the abuser is not allowed to be involved in resident care until the facility investigates. On 1/11/13 at 2:01pm, E8 (RN) stated that if a care giver is accused of verbal abuse, they would not be allowed to work with the resident during the facility's investigation. On 1/11/13 at 2:31pm, E2 (Assistant Administrator) was asked if the statements Z1 made to R1 constituted abuse? E2 stated "I don't know if I can answer yes or no, but it certainly raised concerns." E2 also stated that if it was his mother, he wouldn't have wanted Z1 with her. E2 added "If this was a staff of our own, they would be reassigned or taken off duty." On 1/11/13 at 2:56pm, E2 stated that if an employee was accused of abuse, they would be immediately taken off duty and investigated. But when asked what's the policy if the accused was a caregiver, E2 replied "the family may choose to replace them. The family looks to us for guidance." The facility's Abuse Prevention policy documents: "Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Accused individuals not employed by the facility will be denied unsupervised access to the residents during the course of the course of the investigation. Protection of residents: Even if the resident might not comprehend disparaging comments, verbal or mental abuse might have taken place if the intent was willful and the content abusive. Verbal or mental abuse is just that much more harmful if the intent was willful, the intent was abusive, and the resident intimidated, frightened, or harmed by the remarks. Employees of this facility who have been accused of abuse, neglect or mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee. Employees accused of possible abuse, neglect or misappropriation of property shall not complete the shift as a direct care provider to residents."