Every finding on record at Elevate Care Regency

Based on interview and record review, the facility failed to ensure safe wheelchair transport and failed to immediately respond to a resident's complaint of pain following an incident for 1 of 4 residents (R1) reviewed for accidents and supervision in a sample of 4. This failure resulted in R1 sustaining a fracture of the left femur after R1's left foot became caught in the wheelchair during transport by staff, requiring surgical intervention.Findings Include:On 7/5/2026 at 3:15 PM, R1 was observed lying in bed with an immobilizer in place on the left leg. R1 stated that she underwent surgery after sustaining a fracture when V3 (Certified Nursing Assistant/CNA) was pushing her in a wheelchair and her foot became caught underneath the footrest, causing her left leg to bend. R1 stated that she told V3 to stop when her foot became caught; however, V3 did not stop immediately and continued pushing the wheelchair. R1 stated, I told her, 'Hold on, stop, stop!' but she continued. I had pain and I told them.On 7/5/2026 at 5:06 pm, an interview was conducted with V3 (CNA) regarding the incident involving R1. V3 stated that on 4/18/2026, she was pushing R1 in a wheelchair from the nurses' station toward R1's room when R1's foot came out of position and R1's shoe came off. V3 stated R1 yelled, Stop, stop, and she stopped the wheelchair. V3 added the wheelchair had only traveled a short distance and had not been pushed all the way down the hallway. V3 then assisted R1 by placing the shoe back on before continuing to R1's room. V3 stated that R1 was complaining of pain at the time R1 was transferred from the wheelchair to the bed, and V3 reported the complaint to the nurse. V3 further stated that she also worked the 3:00 PM to 11:00 PM shift that day and R1 continued to complain of pain; however, the X-ray was not completed until the following day.On 7/6/2026 at 11:41 PM, V5, (R1's son), stated that R1 informed him that while an aide was pushing R1'S wheelchair, R1 asked the aide to stop because her foot had become caught underneath the wheelchair footrest. V5 stated that, according to R1, the aide did not stop immediately and continued pushing the wheelchair dragging her foot. V5 further stated, R1 has numbness on the left side of her body, so they should be very careful when moving her. V5 also stated that the facility social worker informed him that there was video footage of the incident captured by the facility camera system; however, according to V5, the facility refused to allow him to view the recording.On 7/6/2026 at 12:19 PM, V4, (Licensed Practical Nurse/LPN), stated that when she worked the morning shift the following day of the incident, 4/19/2026, R1 requested that she look at her leg because she was experiencing pain. V4 stated, R1 requested an X-ray because she had been having pain. V4 further stated that R1 was alert and oriented x 3 and able to express her needs. Although English was not R1's primary language, V4 stated that R1 was able to communicate good in English.On 7/6/2026 at 2:07 PM, V2 (Director of Nursing/DON) stated that on 4/18/2026 V3 was pushing R1 in her wheelchair to her room before the end of the 7:00 AM to 3:00 PM shift. V2 stated that while the CNA was pushing R1 down the hallway, it appeared that R1's left shoe came off, and the CNA immediately stopped and placed the shoe back on. V2 stated that R1 had left-sided weakness and was not wearing appropriate footwear. V2 further stated that the shoe may not have been fully secured.On 7/6/2026 at 4:17 PM, V6 (LPN) stated that V3 was pushing R1 back toward her room so that R1 could lie down. V6 stated that R1 was wearing inappropriate footwear and that R1's left foot, which was her affected side due to prior left-sided weakness from a stroke, slipped off the wheelchair footrest and appeared to graze the floor. V6 learned that the injury may have resulted from the foot striking the ground while R1 was being pushed in the wheelchair.V6 further stated that the CNA later reported that R1 had begun complaining of pain after being transferred back to bed.V6 acknowledge that he administered pain medication to R1 on 4/18/2026 at approximately 8:58 PM, which appeared to be effective. When asked whether the incident could have been prevented, V3 stated, Part of me wants to say no, but yeah, of course it could have been prevented. V3 further stated that residents with physical limitations require extra caution during movement and transport.R1 has left-sided weakness and is wheelchair-bound, V6 stated that R1 was wearing improper footwear at the time of the incident. V6 further stated that R1 did not have a wheelchair foot support or foot-positioning device in place to help prevent the feet from slipping off the footrests, particularly given R1's limited control of the affected foot due to left-sided weakness. R1 should have been carefully transported with appropriate assistance during wheelchair mobility to ensure her safety and prevent injury. Record review revealed the following:R1's care plan initiated on 3/15/2026 states that R1 has ineffective coping related to anxiety disorder. One of the interventions initiated on 3/15/2026 states, Monitor R1 for safety. R1 is taking anti-anxiety meds which is associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs.R1 was the one requested for an X-ray due to continued pain. Review of the nurses' notes dated 4/19/2026 stated the following documentation, in part: Resident stated that her foot was painful and that she wanted to request a foot X-ray to make sure it was fine.According to the facility's Incident Procedure (undated), In the event in incident occurs, the following steps are required: The nurse shall perform a full, head to toe assessment of any resident in which an accident has occurred to identify actual or potential injuries; this includes ROM (range of motion to extremities, evaluation of pain, deformities, shortening of limbs, vital signs, and blood sugar levels (when applicable).Review of the eMAR (Electronic Medication Administration Record) revealed that nurses were aware of R1's pain and administered pain medications to R1 on three (3) occasions following the incident: 4/18/2026 at 8:58 PM, 4/19/2026 at 10:47 AM, and 4/19/2026 at 6:12 PM. However, R1's medical record lacked documentation of a head-to-toe assessment to identify actual or potential injuries following the incident, as required in the facility's Incident Procedure.

Based on observation, interview, and record review, the facility failed to ensure that 2 of 4 residents (R8, R98) who entered the facility without pressure ulcers received the necessary treatment and services to prevent the development of new pressure ulcers and to promote the healing of existing ulcers. Specifically, the facility failed to implement mandatory pressure-redistribution protocols and provide timely incontinence care for a ventilator-dependent resident (R8) and a quadriplegic resident (R98). This failure to provide essential clinical services resulted in the development of a facility-acquired Stage 4 sacral pressure ulcer for R8 that was observed to be actively hemorrhaging, and a facility-acquired unstageable pressure ulcer for R98, who was found in a prolonged soiled state.The findings include: R98 is a [AGE] year-old quadriplegic with a facility-acquired unstageable right gluteus pressure ulcer. Observation of Discomfort (03/23/2026): At 10:47 AM, R98 informed two surveyors he was uncomfortable and requested to be moved up in bed. LPN V10 was unable to identify the assigned CNA (V12), who had not yet provided care or repositioning as of 11:00 AM. Observation of Prolonged Neglect (03/24/2026): At 11:30 AM, two surveyors requested to observe R98's wound. As V10 (LPN) and V21 (CNA) repositioned the resident—who again requested help for repositioning due to discomfort—surveyors observed the resident in a heavily wet incontinence brief. The moisture had saturated through the resident's linens and onto the air mattress. Surveyors observed a visible yellowish circle of wetness with a darkened yellow circumference ring. Clinical Significance: The presence of a darkened circumference ring indicates that the urine had remained on the linens long enough for evaporation and concentration to occur, proving a prolonged lapse in hygiene care. This exposure to moisture and caustic body fluids directly compromised the integrity of the skin and the healing potential of the resident's unstageable wound. Clinical Impact: The facility's failure to provide a fixed, mandatory turning and toileting schedule resulted in the resident's facility-acquired unstageable wound being exposed to prolonged moisture and friction, directly impeding the healing process and causing documented resident distress. (R8): Failure to Implement Treatment for Stage 4 Wound R8 is a [AGE] year-old, non-verbal, ventilator-dependent resident with a facility-acquired Stage 4 sacral pressure ulcer (6.4 cm x 10.6 cm). Observation of Hemorrhage (03/24/2026): At 9:50 AM, during a dressing change, the sacral wound (the size of a tennis ball) was observed with 20% slough and active bleeding. The resident's dressing and incontinent pad were saturated with blood. Failure to Implement Physician Orders: Despite a Nurse Practitioner (NP) order on 03/23/26 to turn every two hours, the facility failed to execute this treatment. On 03/25/2026, R8 was observed lying in a continuous supine position—directly on the hemorrhaging Stage 4 wound—from 9:50 AM to 12:05 PM (2 hours and 15 minutes) without any staff intervention. On 03/25/2026, the Director of Nursing (V2) stated that Staff should turn and reposition every two hours. However, clinical observations proved this was not occurring. Staff Admissions: LPN V10's inability to identify staff assignments and the discovery of R98 in a state of dried-ring incontinence moisture confirm that the facility lacked a functioning system for monitoring and delivering pressure ulcer care. Care Plan Deficiency: The facility utilized discretionary language in the care plans (May reposition) which allowed staff to bypass the NP's mandatory 2-hour turning order and basic hygiene requirements. The facility's failure to provide the necessary treatment and services required by F686 resulted in the two facility-acquired pressure ulcers. The facility allowed a quadriplegic resident to remain in a soiled state for a duration long enough to saturate an air mattress and create dried rings of urine on the linens, while simultaneously failing to reposition a ventilator-dependent resident with an actively bleeding Stage 4 wound. This lack of clinical intervention directly led to the development and worsening of life-threatening deep tissue injuries. Surveyors were unable to obtain an interview with V39 Wound doctor after multiple attempts and calling on 3/25/26 at 5:15 PM and again on 3/26/26 at 10:20 AM and 4:50 PM. R8 is a [AGE] year-old, male originally admitted in the facility on 07/15/23 with the following diagnoses: Anoxic Brain Damage, Not Elsewhere Classified; Chronic Respiratory Failure with Hypoxia; Encounter for Attention to Tracheostomy; Encounter for Attention to Gastrostomy; and Dependence on Respirator (Ventilator) Status. MDS (Minimum Data Set) dated 08/08/25 documented R8 has short- and long-term memory problems; with cognitive skills for daily decision making severely impaired. MDS (Minimum Data Set) dated 02/05/26 documented R8 has one unhealed pressure ulcer/injuries. On 03/23/26 at 11:05 AM, R8 was observed in bed; nonverbal, opens eyes but unable to follow commands and instructions, unable to move self. R8 is bedbound, with ongoing tube feeding of Glucerna at 70 ml/hr (milliliters per hour). R8 has tracheostomy tube connected to ventilator for respiration. R8's Wound Evaluation and Management Summary dated 03/20/26 documented: Stage 4 pressure wound on the sacrum, measurements 6.4 cm x 10.6 cm x 0.5 cm. R8's POS (Physician Order Sheet) recorded: 03/20/26 - Sacrum: cleanse with NSS (normal saline solution)/apply Dakin's soaked gauze/cover with DPD (dry protective dressing) daily for 30 days every day shift every Saturday Sunday for pressure ulcer for 30 days. 03indings include:/20/26 - Sacrum: cleanse with NSS/apply Dakin's soaked gauze/cover with DPD daily of 30 days every day shift every Monday Tuesday Wednesday Thursday Friday for pressure ulcer for 30 days. On 03/24/26 at 9:50 AM, wound care was observed performed by V8 (Wound Care Coordinator). R8's pressure wound on the sacral area is approximately the size of a tennis ball, appearing red, with 20% slough; bleeding was noted. R8's wound dressing and incontinent pad were saturated with blood. Despite the active hemorrhage and the NP's order, R8 was observed lying in a continuous supine position—placing direct, unrelieved pressure on the bleeding Stage 4 wound—from 9:50 AM to 12:05 PM (2 hours and 15 minutes). No staff entered the room to perform the required repositioning during this period. R8's care plan recorded: Has potential for further skin breakdown/pressure ulcer/diabetic ulcer due to immobility, bowel incontinence dated 03/01/26: Interventions: Follow facility protocols for treatment of injury.May reposition every 2 hours as needed NP (Nurse Practitioner) progress notes dated 03/23/26 documented in part: turn every two hours. On 03/25/26 at 9:50 AM, random observation conducted every 15 minutes over a two-hour period revealed R8 was not repositioned. From 9:50 AM to 12:05 PM, he was observed in bed, in a supine position. On 03/25/25 10:30 AM, V36 (Registered Nurse, RN) was asked regarding interventions in management of pressure ulcers. V36 stated residents with pressure ulcers should be turned and repositioned every two hours. V27 (RN) and V38 (Certified Nurse Assistant, CNA) also stated residents are turned every two hours. V27 verbalized R8 should be turned and repositioned every two hours. On 03/25/2026 at 12:28 PM, V8 was interviewed regarding R8. V8 replied, R8 has sacral pressure ulcer Stage 4, a facility acquired. It was identified on 11/24/25 as Unstageable. He needs to be turned and repositioned every two hours and as needed. On 03/25/2026 at 2:55 PM V2, (Director of Nursing) was asked regarding pressure ulcers. V2 stated, Staff should turn and reposition every two hours and as needed. Facility's policy titled Pressure Ulcer Prevention Protocol dated 05/18 stated in part but not limited to the following: Procedure: 4. Intervention necessary to maintain skin integrity or to promote healing will be incorporated in to the plan of care based on each resident's individual needs and risks, which may include: E. Any other factor identified on the risk assessment including but not limited to nutritional support, positioning/support devices, or medication review. 5. The resident's care plan will indicate the resident's risk factor (s) and include individualized interventions as needed for a comprehensive pressure ulcer prevention program.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. Specifically, the facility failed to: 1. Discard expired food items. 2. Maintain current records for sanitizing solution changes. 3. Maintain required temperatures for hot and cold food items during service. This deficient practice has the potential to affect all 155 residents who receive food from the kitchen.A. Expired Food Storage: On 03/23/2026 at 10:45 AM, during the initial tour of the kitchen, the following items were observed in the first reach-in refrigerator:Six (6) plates containing Jello, mixed fruit cups, and cottage cheese, all labeled with a date of 03/20/2026.Ten (10) individual cups of chopped watermelon labeled with a date of 03/20/2026.Twelve (12) fruit cups with varying dates of 03/20/2026 and 03/21/2026.Twelve (12) pudding cups labeled with a date of 03/21/2026.As of 03/23/2026, these items had exceeded the facility's 48-to-72-hour window for fresh prepared/opened items and remained available for service to residents.B. Sanitation Monitoring: On 03/23/2026 at 10:45 AM, the sanitizing bucket log located on the door of the reach-in refrigerator was reviewed. The log indicated the last date the sanitizing buckets were changed and tested for concentration was 03/21/2026. The facility failed to provide evidence that sanitizing solutions used in food preparation areas were changed or monitored for efficacy for a period of 48 hours prior to the survey. During the course of the food preparation for the lunch time meal, there were no staff observed utilizing the sanitation buckets to obtain sanitized rags to wipe down any surface areas after prepping.C. Improper Holding and Serving Temperatures: On 03/24/2026 at 1:08 PM, during a test tray audit and meal service observation, the following temperatures were recorded:Hot Food: A meat portion (specifically Beef Stroganoff) was tested for internal temperature upon arrival at the resident dining area. The internal temperature was measured at 131 F. CMS professional standards and the FDA Food Code require hot foods to be held and served at 135 F or higher.Cold Food: A dessert pudding was tested for internal temperature. The Dietary Manager provided a reading of 70 F. CMS professional standards require cold TCS (Time/Temperature Control for Safety) foods to be maintained and served at 41 F or below.The facility failed to ensure that food was kept out of the Danger Zone (41 F-135 F), where pathogenic bacteria grow rapidly. Specifically, the pudding was held 29 degrees above the maximum allowable cold-holding temperature.Interview Findings: On 03/25/2026 at 1:20 PM, V3 (Dietary Manager) confirmed the above findings. V3 contended that a higher temperature might have been reached if the thermometer was placed deeper into the meat and suggested the 70 F pudding reading might be due to not wiping the thermometer with alcohol. However, V3 provided no secondary temperature reading to refute the initial findings. These statements by V3 indicate a failure to follow standardized thermometry protocols to ensure accurate food safety monitoring. Furthermore, V3 confirmed that as of the time of the audit, the facility was not meeting the professional standards for food service safety.

Based on observation, interview, and record review, the facility failed to implement its water management program to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens. Specifically, the facility failed to: 1. Adhere to its own internal protocol regarding weekly water flushing after receiving a moderate caution test result. 2. Repair or resolve a malfunctioning chemical dispensing system intended to mitigate pathogen growth, which has been malfunctioning for over 60 days. 3.Implement necessary clinical and environmental safeguards, including failing to relocate a resident currently residing in a room identified as a Legionella source. This deficient practice can posed a risk to the health and safety of R185 and has the potential to affect all 166 residents, staff, and visitors utilizing the facility's water system.Findings include:There are 166 residents currently residing in the facility.According to Legionella report dated 12/31/25, the following were the results of the water tests:room [ROOM NUMBER] sink - legionella detected: 0.1 CFU/ml (colony forming units per milliliters)room [ROOM NUMBER] sink - legionella detected: 0.1 CFU/mlroom [ROOM NUMBER] shower - legionella detected: 6 CFU/ml On 03/24/26 at 11:54 AM, V31 (Manager, water service treatment company) was interviewed regarding legionella report on 12/31/25. V31 stated, The recent test we did was last December 2025. 0.1 indicates the presence of Legionella bacteria in the water sample of that specific point of view. CDC (Centers for Disease Control) says under 1 means well-controlled. You don't have to do anything, we recommend flushing on any positive results. 6 means a moderate concern and requires action and recommended testing upon remediation. Do flushing and use secondary disinfection. Retesting is after the remediation which is flushing utilizing secondary disinfection and testing after completion. We did the testing only today. V31 was asked on why water re-testing was only done today, replied We did the December 2025 and results came back January 2026. February we came back but there was an issue with the secondary disinfection unit. We came back today and collected water samples for legionella testing for the three specific areas in the facility. 7-10 business days when results come back. On 03/24/26 at 12:20 PM, V32 ((Maintenance Director/Supervisor) was asked regarding measures to control the legionella level in room [ROOM NUMBER] shower. V32 stated, We did monthly flushing of the specific areas started January 2026 until today. We also have secondary disinfection, which is a computer system wherein chemicals are injected into the water system which checks and measures the flow of water in the facility. February 2026 when the company came back, one of the pumps from the disinfection system was not working properly so retesting was not done. I have to reset the system for the secondary infection every day to do the disinfection. The company came back today. The room [ROOM NUMBER] shower was not in use at the time when testing was done. The resident who used to occupy that room was bedbound resident and did not use the shower in the bathroom. The current resident is I believe using the shower. V32 was also asked regarding the process of flushing and secondary infection. V32 verbalized, I do the flushing (open both hot and cold water) and run for a minimum of 15 minutes every month on the shower in room [ROOM NUMBER].I did not do the flushing weekly, I did it monthly, flushing only. The secondary disinfection is an ongoing process for the whole water system in the facility. One of the pipes was accumulating a small bubble and has to reset it constantly. The other pump is working but the other one. I don't remember when this other pump was not working. If the alarm goes off, I keep on resetting the disinfection system. I have kept on resetting the system every day since January 2026. I don't remember exactly when it started to alarm. V31 is in charge of the system. When he (V31) comes to the facility, he checks the system. I don't know when he found out about this. It is not me who takes care of the system; I just do what he told me. I don't do documentation if there is an issue, I was told not to, so I don't document.Per electronic medical records, R184 was the resident who occupied room [ROOM NUMBER]. R184 was discharged from the facility on 03/14/26. R185 is the current resident occupying R00m 107 and was admitted on [DATE]. On 03/24/26 at 3:00 PM, R185 was asked if she was using the shower. R185 stated she was using the shower in her bathroom.Facility's domestic water logs documented:02/04/26 - room [ROOM NUMBER] shower: flush 15 minutes hot and cold03/14/26 - room [ROOM NUMBER] shower: flush 15 minutes hot and cold On 03/24/26 at 2:25 PM, V34 (Vice President of Physical Plant) was asked regarding legionella issues in room [ROOM NUMBER] shower. V34 stated, We got the result of 6 CFU/ml and it was moderate level. We continue flushing and shower is not used in facility. They came back today and did water retesting. We actually have a system in place that injects chloramine into water for secondary disinfection; and flushing. We don't do daily flushing; we do weekly flushing. We can increase the flushing, and the sanitation put into the system. On 03/25/26 at 10:43 AM, secondary disinfection computer system was observed with V32. The facility's disinfection system was in the boiler room. There were two pumps that inject chemicals into the water stream, which caters for the whole facility. V32 stated, I don't recall when the left injection pump sensor was not reading, giving an alarm. If the sensor is not working, it accumulates some bubbles, so I had to bleed some bubbles out. Since my office is in the boiler room, every time I hear the alarm, I reset it until yesterday. V31 came yesterday and changed the sensor and now it's working. Last December 2025 was the last water test. V31 comes once a month. He probably came back in January 2026 and did not do the testing. I actually don't remember if it was January. I was on vacation two weeks ago. Last January, I took a couple of days because of sickness. Two weeks ago, I was on vacation. V33 (Maintenance) is the one resetting the machine. V31 told me to flush the 107 shower monthly for 15 to 20 minutes. Now it's fixed. I probably forgot, I don't remember if I notify V1 (Administrator) about the system issue. I don't notify V34 because he gets copies of work requests and repairs done by the water company. I assumed V34 should tell her (V1). On 03/25/26 at 11:02 AM, V33 was asked regarding secondary disinfection. V33 stated, Secondary disinfection is for the domestic water system in the facility. It injects chemicals to water for the whole building, to kill bacteria and legionella in water. When V32 was on vacation two weeks ago, I was instructed to reset the system when alarm goes off. I did it maybe twice when he was on vacation. When he (V32) came back, I saw him a couple of times resetting the system. On 03/25/26 at 1:08 PM, V1 stated during interview that she was not aware of any positive legionella results last December 2025 nor concerns related to system of the secondary disinfection. V1 also verbalized that Legionella can cause Pneumonia and death. Facility presented the following policy related to water testing:Overview Risk Analysis of Water systemsShower- risk assessment: high; showers have been documented sources of Legionella contamination individual units pose much greater risk; CCP (Critical Control Points) code: CCP1Domestic Hot Water CCP1 Legionella Response Overview>0-10CFU Flush out Outlet for at least 15-20 minutes; Clean aeratorsFrequency of flushing: All outlets of domestic hot water sources, especially showers, must be exercised normally. We recommend a free chlorine testing of each shower on hot water to test for this monthly by Staff until a residual of >.1ppm is found. This test should be done by onsite staff with test kits of colorimeters. It is responsibility of onsite staff to carry this out. This not only insures flushing, but documentation as well on the flushing and chlorine residual. The flushing should be done by turning on the hot water, until at the temperature of the domestic hot water loop, then test taken. If there is no residual, flush system for at least 15-20 minutes, both hot and cold, then retest just the hot. All showers and high-risk sinks should be done weekly to begin with, then experimentation can be done to back off schedule from weekly to bi-weekly, then monthly.

Based on observation, interview, and record review, the facility failed to ensure that residents' needs and preferences were reasonably accommodated by failing to: 1. Maintain functioning call lights within reach for residents with significant physical and cognitive impairments (R1, R82, R95). 2. Provide timely responses to call lights, with wait times exceeding 20 minutes for assistance with basic needs such as toileting and repositioning (R95, R98). 3. Implement a system to anticipate the needs of residents who are unable to utilize standard call lights (R95). This deficient practice affected 4 of 4 residents (R1, R82, R95, R98) reviewed for reasonable accommodations in the sample of 45 and has the potential to affect all residents residing in the facility, as evidenced by recurring Resident Council grievances regarding call light response times.Findings Include:R1 is an [AGE] year-old resident with diagnoses of, but not limited to, traumatic subdural hemorrhage with loss of consciousness, status unknown, subsequent encounter, other nondisplaced fracture with routine healing, other nondisplaced fracture of seventh cervical vertebra, subsequent encounter for fracture with routine healing, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.R82 is a [AGE] year-old resident with diagnoses of, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, malignant neoplasm of colon, unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance, and history of falling.R95 is a [AGE] year-old resident with diagnoses of, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the dominant right side, depression, unspecified, and need for assistance with personal care.R98 is a [AGE] year-old resident with diagnoses of, but not limited to, sepsis, unspecified organism, acute and chronic respiratory failure with hypoxia, pneumonia, unspecified organism, quadriplegia, unspecified, and need for assistance with personal care.On 03/23/3036 at 11:05 AM, R82 was observed lying in their bed and did not have a call light within their reach. Call light was observed hanging off the bed, behind the resident.At 11:15 AM, R1 was observed lying in their bed and did not have a call light within their reach; call light was observed hanging underneath the bed.At 11:40 AM, R95 was observed lying in their bed and their call light was hanging near the floor on the left side of their bed. R95 stated that they don't use their call light, they yell out to get the attention of staff.At 11:45 AM, it was observed that resident was unable to pull call light from its position of hanging near the floor on the left side of the bed.At 11:50 AM, after five minutes, V5 (certified nursing assistant), came into R95's room and told R95 that she would get their certified nursing assistant to come help the resident. R95 told V5 that they needed assistance with changing/toileting because they had not been changed or toileted today.At 12:05 PM, V5 came in with V15 (certified nursing assistant), R95's regular certified nursing assistant, to assist resident; 20 minutes have passed since call light was initiated by surveyor. V5 and V15 asked R95 if she had to have a BM; R95 stated that they would try to go in their brief while lying flat in the bed.At 12:10 PM, it was observed that R98 slid down in their bed, head was below head pillow and right arm was dangling from the right side of the bed. Surveyors (myself and another person) asked R98 if they were comfortable and they stated they were not comfortable and would like to be moved up in bed. This surveyor asked if they could call for assistance from the staff. At this time, R98 did so by using a mouthpiece device connected to the call light system. V8 (wound care coordinator) came into R98's room, six minutes following call light initiation, to turn off call light and stated to R98 that they would get someone to help.At 12:20 PM, V11 (certified nursing assistant) and V10 (licensed practical nurse), entered R98's room to assist with needs. R98 requested to be moved up in the bed and toileted. Ten minutes passed between call light initiation and care being initiated.On 03/24/2026 at 2:00 PM, record review of R98's electronic chart showed a medical diagnosis of quadriplegia, unspecified, on 10/14/2021.On 03/25/2026 at 11:00 AM, this surveyor interviewed V9 (licensed practical nurse) who was assigned to the fifth floor/dementia unit where R1 and R82 reside. V9 stated they have worked within the facility for almost three years as a licensed practical nurse. V9 stated the expectation within the facility when a resident initiates a call light is to get to the resident within one to two minutes to attend to the needs of the resident. V9 stated that on the dementia unit, call light usage rate is lower, therefore, the expectation is to check on the residents more frequently. V9 stated that the wait time for answering call lights should be as soon as possible.On 03/25/2026 at 11:15 AM, this surveyor interviewed V10 who was assigned to the fourth floor where R95 and R98 reside. V10 stated that call lights on the unit should be answered as soon as possible but that any time over five minutes would be considered unacceptable in her opinion. V10 stated that anyone on the floor can answer call lights and is expected to do so as quickly as possible.At 11:20 AM, this surveyor interviewed V11 (certified nursing assistant) who has worked at the facility for six years and, for the last three years, exclusively works on the fourth floor. V11 states that the call light expectation on their floor is as soon as possible. V11 states that anything over seven to ten minutes would be considered unacceptable.At 11:30 AM, this surveyor interviewed V2 (director of nursing) regarding the facility's call light policy. V2 stated that call lights are to be answered as soon as possible.On 03/24/2026 at 10:00, this surveyor attended a resident council meeting, and residents discussed call light answer times to be an issue. Residents said the time during overnight hours has ranged from one and a half to three and a half hours and during the day the average wait time, resoundingly, was 20-30 minutes.On 03/26/2026 at 2:30 PM, record review of resident council minutes from 09/25/2025 stated that CNAs (certified nursing assistants) take too long to answer call lights.At 2:35 PM, record review of resident council minutes from 11/20/2025 stated that CNAs (certified nursing assistants) take a considerable amount of time to answer call lights.At 2:40 PM, record review of resident council minutes from 12/30/2025 stated that call lights are pulled and frequently not answered at all.On 03/24/2026 at 2:00 PM, record review of R98's electronic medical administration record identified a care plan that stated in part but not limited to:R98 has inability to transfer self R/T impaired mobility, quadriplegia. Pt. is a Hoyer Lift for transfers. Ensure resident is comfortable and feels secure.Facility Policy titled, Call Light, dated 06/2021 stated in part but not limited to:Objective: To respond to residents' requests and needs.Equipment: Functioning call light placed where it is accessible to the resident.Procedure: Staff are to answer the call light in a prompt, calm, courteous manner.Listen to residents' requests. Do not make him/her feel that you are too busy to help.For residents who cannot utilize the call light, the staff must monitor the residents more frequently and attempt to anticipate the residents' needs.

Based on observation, interview, and record review, the facility failed to ensure that for 4 of 4 residents (R36, R98, R1, and R81) in the sample of 45 for comprehensive care plans were developed with directive, measurable interventions and implemented as written. The facility established a pattern of drafting care plans using non-directive, permissive language (May) for high-risk clinical areas, including pressure ulcer prevention. Furthermore, the facility failed to implement mandatory care plan interventions related to incontinence care, rehabilitative nursing (Passive Range of Motion), and psychosocial monitoring. This failed practice represents a systemic failure to use the care plan as a directive clinical tool, affecting residents with high-acuity needs including Multiple Sclerosis, Quadriplegia, and Dementia. R1 is an [AGE] year-old resident with diagnoses of, but not limited to, traumatic subdural hemorrhage with loss of consciousness, status unknown, subsequent encounter, other nondisplaced fracture with routine healing, other nondisplaced fracture of seventh cervical vertebra, subsequent encounter for fracture with routine healing, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On 03/23/2026 at 11:10 AM, R1 was observed lying in bed within their room. R1 appeared disheveled with a dirty gown intact, bed sheets stained with an unknown liquid near the head and chest and did not have their call light within reach. Resident was calling out, mommy and intermittently laughing. On 03/26/2026 at 12:20 PM R1's Care Plan dated 03/02/2026 was reviewed and indicated non-directive language in reference to reducing the risk for skin breakdown/pressure ulcer. This Care Plan reads but is not limited to: May use low air loss mattress for pressure reduction. May use cushion while up in wheelchair/ geri chair for pressure reduction. May reposition q 2 hours and as needed. May offload heels/ wear heel boots for pressure reduction. May apply house stock barrier cream after each incontinent episode and as needed. (CNA may apply) R81 is a [AGE] year-old resident with diagnoses of, but not limited to, unspecified dementia, unspecified severity, other behavioral disturbance, major depressive disorder, single episode, history of falling, and autistic disorder. On 3/23/2026 at 10:50, R81 was observed in the dining room, sitting at a table in a dining room chair. R81 was banging her hand on the table and shouting out, mommy. When surveyors walked into the dining room and made introductions, V13 (certified nursing assistant) came over to resident to address behaviors. V13 and V40 (activity aide) assisted resident with a transfer from dining room chair to wheelchair and then handed her crayons and a coloring sheet; these interventions stopped the behaviors and calmed the resident down. On 03/26/2026 R81's Care Plan dated 02/02/2026 was reviewed and indicated non-directive language in reference to reducing the risk for skin breakdown/pressure ulcer. This Care Plan reads but is not limited to: The resident has potential for skin breakdown/ pressure ulcer due to Chronic contracture of BLE, incontinence and limited mobility.Braden Scale 17 May use cushion while up in wheelchair/ geri chair for pressure reduction. May reposition q 2 hours and as needed. May offload heels/ wear heel boots for pressure reduction. May apply house stock barrier cream after each incontinent episode and as needed. (CNA may apply) On 03/25/2026 at 11:45 AM, an interview was conducted with V2 (Director of Nursing) and V8 (Wound Coordinator) regarding the pervasive use of non-directive language in the Comprehensive Care Plans for Residents R1, R36, R81, and R98. V2 (director of nursing) stated to the survey team that care plans are intentionally written using May verbiage because that was how they were trained and asserted that the language reflects the resident's right to refuse. When surveyors pointed out that interventions are meant for staff to assist or carry out—especially for residents identified as Dependent—V2 responded that the care plans were for the resident to follow and not for staff. V8 (Wound Coordinator) affirmed V2's statement regarding the use of May. While initially hesitant, V8 eventually acknowledged the surveyors' point that using optional language for essential skin-care interventions (such as repositioning and barrier cream application) failed to provide staff with mandatory clinical direction. Despite all four residents being identified as physically dependent on staff for ADLs, the facility developed care plans that failed to provide directive instructions. R1 is an [AGE] year-old with a C7 fracture and dementia. The Care Plan dated 03/02/2026 stated staff May reposition q 2 hours and May offload heels. R81 is a [AGE] year-old with chronic contractures and a Braden Scale of 17. The Care Plan dated 02/02/2026 stated staff May use cushion while up in wheelchair and May apply house stock barrier cream. Where the facility did include directive language, it failed to ensure implementation, leading to the neglect of residents with complex conditions. Resident R36: The Care Plan mandated incontinence care minimum every 2 hours. The resident was found in a crystallized brief and overfilled colostomy bag, having gone 18 hours without care. R98's Care Plan required a highly specific PROM Passive Range of Motion Program involving 10 reps x 2 sets of limb flexion. Observations on 3/25/26 at 10:45 AM of the resident's environment and hygiene status confirmed these PROM exercises were not implemented. Conclusion: The facility demonstrated a systemic pattern of developing non-comprehensive, non-directive care plans and a concurrent failure to implement directive interventions. The Director of Nursing's admission that care plans were for the resident to follow and not for staff confirms a facility-wide misunderstanding of the regulatory requirement for care plans to serve as the primary vehicle for directing staff care for dependent residents.

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain grooming and personal hygiene for 4 of 4 residents (R1, R4, R82, R95) reviewed for activities of daily living (ADLs) in a sample of 45. The facility failed to ensure that residents who were unable to carry out ADLs independently were kept clean, well-groomed, and in a sanitary environment. Specifically, residents were observed slumped in chairs, in soiled bed linens with dried liquids, with greasy/unkept hair, and in saturated incontinence briefs. This deficient practice represents a systemic failure to provide basic ADL support and has the potential to affect all dependent residents in the facility. Findings Include:R1 is an [AGE] year-old resident with diagnoses of, but not limited to, traumatic subdural hemorrhage with loss of consciousness, status unknown, subsequent encounter, other nondisplaced fracture with routine healing, other nondisplaced fracture of seventh cervical vertebra, subsequent encounter for fracture with routine healing, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.R4 is a [AGE] year-old female with diagnoses but not limited to, unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, hemiplegia, unspecified affecting right dominant side, schizoaffective disorder, unspecified, need for assistance for personal care.R82 is a [AGE] year-old resident with diagnoses of, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, malignant neoplasm of colon, unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance, and history of falling.R95 is a [AGE] year-old resident with diagnoses of, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the dominant right side, depression, unspecified, and need for assistance with personal care.On 03/23/2026 at 10:50 AM, R4 was observed in the dining room sitting in a geri chair. R4 appeared disheveled (greasy hair, dandruff present, and food on clothing) and was slumped down in the chair in an uncomfortable looking position.At 11:10 AM, R1 was observed in their bed, in sheets that were soiled with an unknown liquid that had dried, near the head/chest area, hair was disheveled and greasy, and R1 was in a hospital gown that appeared dirty.At 11:20 AM, R82 was observed lying in their bed. Bedsheets were soiled around the head, there was a bib bunched up on the resident's chest with food on it, resident was in a stained hospital gown that was unbuttoned on the shoulder, and hair appeared to be greasy.At 11:40 AM, R95 was observed lying in bed and stated they were in the same clothes (hospital gown) as yesterday and stated that no one had checked on them yet. R95 stated they were wet and wanted to be changed. V5 and V15 came into room after surveyor assisted resident with call light that was out of reach, and upon observation, R95 did have a wet/saturated diaper.On 03/24/2026 at 11:15 AM, this surveyor interviewed V12 (certified nursing assistant) regarding resident hygiene expectations. V12 stated that if they were to see a resident that appeared disheveled and in need of hygiene care, they would speak to the nurse on duty and have them figure out what to do.At 11:20 AM, this surveyor spoke to V18 (certified nursing assistant) who stated they have worked at the facility for 11 years. V18 stated that residents receive 1-2 showers per week, and this is how hygiene is taken care of in the facility.On 03/25/2026 at 11:30 AM, this surveyor spoke to V2 (director of nursing) regarding the facility's activities of daily living policy. V2 stated that if a resident appeared disheveled or unkempt, whichever staff member (nurse or certified nursing assistant) saw this, should address it. Addressing would require informing the nurse on duty of what was seen and then initiating care to residents, as needed. V2 stated that if a certified nursing assistant were to find a resident in this state, the expectation would be that they would promptly assist the resident.On 03/26/2026 at 3:35 PM, record review of R4's care plan reads but is not limited to:R4 has self-care deficit r/t Hemiplegia affecting right dominant side. Risk for ADL Decline related to cognitive impairment, generalized weakness. Resident is under hospice care.At 3:35 PM, record review for R1's care plan reads but is not limited to:R1 is at Risk for ADL decline related to general weakness and deconditioning.At 3:35 PM, record review for R82's care plan reads but is not limited to:Risk for ADL Decline related to; generalized weakness At 3:35 PM, record review of R95's care plan reads but is not limited to:R95 is at risk for ADL Decline related to: generalized weakness, Dx of CVA with (R) side hemiplegia. [NAME] prefers to stay in bed. Refuses to transfer to chair when asked. Facility policy titled, Activities of Daily Living (ADLs), dated 03/03/2023 stated in part but not limited to: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the residents and in accordance with the plan of care, including appropriate support and assistance with:Hygiene (bathing, dressing, grooming, and oral care)Mobility (transfer and ambulation, including walking)Elimination (toileting)Dining (meals and snacks)Communication (speech, language, and any functional communication systems)

Based on observation, interview, and record review, the facility failed to ensure that 1 of 2 residents (R36) was free from neglect in the sample of 45. The facility failed to provide necessary incontinence and ostomy care, resulting in the resident remaining in a crystallized, urine-saturated brief and an overfilled colostomy bag for approximately 18 hours. This failure resulted in the development of Moisture-Associated Skin Damage (MASD), confirmed by the facility Wound Nurse, and caused R36 significant mental anguish.R36 is an alert and oriented [AGE] year-old with diagnoses including Multiple Sclerosis, Emphysema, Cataracts, and colostomy status.1. Observation and Clinical Confirmation of Physical Harm On March 25, 2026, at 10:45 AM, Resident R36 was observed with a crystallized, heavy incontinence brief and a colostomy bag filled to maximum capacity. The urine had saturated the linens and permeated the mattress pad, leaving a yellowish-brown ring.Wound Nurse Interview: On March 25, 2026, at 10:45 AM, V25 LPN Wound Nurse arrived to assess the resident in the presence of two (2) surveyors. The Wound Nurse confirmed: Yes, that is a newly formed MASD located on her lower left buttock and upper thigh area.Clinical Causation: When asked by surveyors how the injury formed, the Wound Nurse V25 stated, It's called MASD because it is caused by moisture such as from sweat or urine and in this case, more likely from her laying in urine so long. He further stated he would need to contact the wound doctor for new orders to treat the injury.2. Staff Confrontation and Psychosocial Impact At approximately 11:00 AM, in the presence of two (2) surveyors, V17 CNA confronted the resident, stating, But you told me you want to be changed last all the time!Resident Rebuttal: R36 (BIMS: 10) responded logically and with clarity: That is not true. Why would I want to lay in my urine overnight and be changed last? That doesn't make sense.Surveyor Interview & Mental Anguish: During the interview, R36 became visibly emotional and teary. She stated, They [the staff] used to get me up and I would go to activities, but they never get me up anymore. She explained that she feels forgotten, noting the CNA was just defending herself and that staff pretend to care but they don't. She concluded by stating she had given up on everything.3. Staff Admissions of FailureCNA admission: The assigned CNA (V17) admitted she performed visual only rounds for positioning but did not physically check the resident's brief or colostomy bag for cleanliness or capacity.Nurse admission: V14 (LPN) The Nurse on duty confirmed the colostomy bag was over 3/4 full and admitted the CNA failed to report the condition, which should have been addressed hours earlier. V14 said when asked by the two surveyors, It is very full and (V17) should have let me know this so it could've been changed earlier. Surveyors asked when (R36) is gotten up, V14 indicated she did not know as she was a float on the floor but acknowledged that she has never seen R36 out of bed. 4. The facility's failure to provide care for R36 between the evening of March 24 and the morning of March 25, 2026, represents a systematic departure from the resident's established Clinical Care Plan.Failure to Implement Incontinence and Ostomy Interventions: Although the resident's Care Plan mandates toileting assistance/incontinence care minimum every 2 hours and as needed, physical evidence observed on March 25 at 10:45 AM confirmed this intervention was not implemented for approximately 18 hours. The resident was found in a crystallized and heavy brief, a clinical state that only occurs after prolonged exposure and extreme saturation, indicating that staff missed at least nine (9) consecutive 2-hour care windows across three separate shifts. Furthermore, the colostomy bag, which the Care Plan requires staff to monitor for output, was filled to maximum capacity, threatening skin integrity and causing the resident significant distress.Failure of Rehabilitative and Social Interventions: The facility further failed to implement the Care Plan mandate for Range of motion (active or passive) with AM/PM care daily. Because the resident remained in the same saturated linens and crystallized brief for 18 hours, it is clinically impossible for staff to have performed the required ROM exercises during either the evening of March 24 or the morning of March 25. This omission directly contributed to the resident's statement that she is never gotten up anymore, contradicting the Care Plan goal for her to express satisfaction with daily routine and leisure activities.Neglect of Psychosocial Monitoring: The facility's own Care Plan directs staff to monitor for tearing, withdrawal, and refusal to attend activities as non-verbal indicators of pain and discomfort. Despite these indicators being present and observed by surveyors-culminating in the resident becoming tearful and stating she had given up-the facility failed to respond to these clinical cues. This lack of intervention resulted in documented mental anguish, as the resident felt her only option was to withdraw from care entirely.5. Facility Assessment and Knowledge of Risk Review of the Abuse/Neglect Risk assessment dated [DATE] revealed the facility had pre-identified the resident as high-risk for neglect due to being bed-bound and requiring total care.Psychosocial Baseline: The assessment documented that the resident was already exhibiting isolation or withdrawal and avoiding interaction.Cognitive Status: The facility confirmed a BIMS of 10, identifying confusion, disorientation or forgetfulness.Despite this documented knowledge that Resident R36 was physically dependent and emotionally withdrawing, the facility failed to implement frequent rounding or assist the resident out of bed for social engagement. This failure directly led to the 18-hour neglect, the development of MASD, and the mental anguish and statement that she had given up on March 25, 2026.Facility Policy: Facility policy revised October 2022 reads in part, Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress . assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident including deprivation of goods and services by staff.

Based on observations, record review, and interviews, the facility failed to ensure that a resident received a therapeutic diet as ordered by the physician for one (R93) of six residents reviewed for dietary services in the sample of 45. Specifically, the facility provided thin liquids to a resident who had a physician's order for nectar-thick liquids.Findings include:R93 is a [AGE] year old female admitted to the facility 9/21/2021with diagnosis including but not limited to Metabolic Encephalopathy; Type 2 Diabetes Mellitus without Complications; Chronic Obstructive Pulmonary Disease; Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris; and Dysphagia, Oropharyngeal Phase.On 03/23/2026 at 12:49 PM Surveyor observed R93 eating lunch at this time. R93's meal ticket shows mechanical soft diet with nectar thick fluids. Thin soup and coffee observed on R93's tray. On 03/24/2026 at 12:20 PM Surveyor observed cup of water and prune juice on the lunch tray at R93's bedside table. Staff observed delivering R93's lunch tray without making adjustments to viscosity of the prune juice. R93 said, Nurses always give me water after I take my medications. Staff also brings me iced water when I ask for it.On 03/24/2026 at 12:28 PM V20 (Registered Nurse) said, I give R93's medications crushed with apple sauce. It was recommended by speech therapy, due to R93's decline and increase in tremors, that R93 takes her medications crushed. R93 is on mechanical soft, nectar thick, no straw diet. Residents on nectar thick diet should not have thin density liquids. R93 can tolerate thin liquids though.On 03/24/2026 at 1:40 PM V2 (Director of Nursing) said, If a resident is on mechanically soft diet with nectar thick liquids that means that they are at risk for aspiration. R93 is getting trialed for thin liquids but if the order is not changed, R93 should be still limited to thick liquids as per current order. R93 should not have water without a thickener. R93 is at risk for aspiration. R93's physician diet order dated 3/10/2026 reds in part, LCS (Low Concentrated Sweets)/NAS (No Added Salt) diet. Mechanical Soft Texture, Nectar/Mildly Thick consistency.R93's speech therapy note dated 3/23/2026 reads in part, Oral Intake: Current Drinks/Liquids = Mildly Thick Drinks MT2. Current Foods/Solids = Minced + Moist Foods MM5. The facility Therapeutic Diets policy dated 1/16 reads in part, Therapeutic diet shall be prescribed by the attending physician. A therapeutic diet must be prescribed by the resident's attending physician. A tray identification system is established to ensure that each resident receives his or her diet as ordered. Mechanically altered diets will be considered therapeutic diets.

Based on interview and record review, the facility failed to provide necessary respiratory care and monitoring for a ventilator-dependent resident by failing to assess and respond to ventilator alarms and failing to ensure the resident's ventilator circuit and closed suction system were intact and functioning. These deficiencies affect one (R1) of four residents in the sample of nine reviewed for quality of care. These failures resulted in R1 not receiving ventilation and being found unresponsive, requiring emergency medical intervention; and expired. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on [DATE] when R1 was found unresponsive, pale and disconnected from ventilator. V1 (Administrator), V2 (Director of Nursing) and V3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 10:31 AM. The survey team confirmed by observation, interviews and record reviews that Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include:R1 is a [AGE] year-old female, admitted in the facility on [DATE] with the following diagnoses: Encephalopathy, Unspecified; Quadriplegia, Unspecified; Chronic Obstructive Pulmonary Disease (COPD), Unspecified; Encounter for Attention to Tracheostomy; Dependence on Respirator (Ventilator) Status; Vascular dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety.MDS (Minimum Data Set) dated [DATE] documented R1 had short and long-term memory problems and her cognitive skills for daily decision making were severely impaired. R1's POS (Physician Order Sheet) dated [DATE] recorded: vent order mode: AC (assist control) rate: 18 AVT (actual tidal volume); 400 ml PEEP (positive end-expiratory pressure): 5 oxygen, 28% fio2 (fraction of inspired oxygen) 2 lpm (liters per minute) via oxygen concentrator continuously every shift. R1's care plans documented:Trache/ventilator dependent related to respiratory failure (revision [DATE]):Interventions: Assess for signs and symptoms of hypoxia: altered level of consciousness, irritability, listlessness, cyanosis.Ineffective breathing pattern/airway clearance related to COPD (revision [DATE]):Interventions: Monitor for signs and symptoms of acute respiratory insufficiency: Anxiety, confusion, Restlessness, SOB at rest, Cyanosis Somnolence. R1's progress notes dated [DATE] documented the following:Time stamped 1:45AM: ventilator alarms intermittently, came to patient's room, suctioned mouth due to copious thin secretions, trach suctioned once with blood-tinged thin secretions, moderate amount. VS (vital signs) checked and recorded. Gtube (gastrostomy tube) dressing changed, gtube is patent and flushing well. No distress noted. Time stamped 4:10 AM: Attention was called by RT (Respiratory Therapist) needing help, patient was found pale, no breathing noted, high quality CPR (cardiopulmonary resuscitation) initiated, code blue called, EMS was called by another nurse, RT started Ambu bagging. A colleague brought in crash cart, CPR board placed at the patient (R1) back, tube feeding disconnected, portable defibrillator placed on patient's chest following defibrillator's guide. Resident (R1) attached to vital sign monitor, with the following reading while high quality CPR is ongoing, BP (blood pressure) 145/107; PR (pulse rate)124; saturation 69%, blood sugar 201. IV (intravenous) access placed right AC (antecubital fossa) gauge 22 with 0.9 running. 10-15 minutes later, paramedics came and took over. ROSC (return of spontaneous circulation) achieved, and paramedics left the facility around 4:55 to hospital. Time stamped 5:42 AM: At 3:55 AM, found patient (R1) unresponsive and disconnected from vent. Vent did not alarm outside room or in room. Code blue called and emergency medical services (EMS) called. Began code blue support on R1 until paramedics arrived 10-15 minutes later to take over code. On [DATE] at 1:18 PM, V4 (Registered Nurse, RN) was asked regarding R1 and incident on [DATE]. V4 replied, R1 was non-verbal, responsive to tactile stimuli. She was on trache/vent 24/7. On [DATE] at 1:45 AM, I did tracheal suctioning because vent's alarm kept going off. I did oral suctioning, and I was able to get saliva. Then, I did tracheal suctioning. There were not many tracheal secretions. I did it once. Everything was still connected. She was connected to the vital signs machine, saturation was okay, vent was not alarming anymore. Around 4 AM, I was close to the nurses' station, saw RT (V5) came to her room and she (V5) called me that she needs a nurse in her (R1) room. I went to her room, and I found her (R1) pale, not moving, no response, no rise and fall of the chest, we started CPR. My other colleague was calling paramedics. Some nurses are already coming. I disconnected her tube feeding, we put the board on the back and continue CPR. No vitals. Defibrillator was used. In the middle of the CPR we got a vital sign, saturation was 69%. V5 was bagging. Paramedics came, when she was transported out, she was revived. Her alarm was working because it alarmed when I did my suction. I didn't touch the machine. Prior to that, I didn't hear any alarm go off. On [DATE] at 3:37 PM, V5 was interviewed regarding R1. V5 stated, I was the one who found her on [DATE] early morning. I was doing rounds a little like 4 AM. When I went to her (R1) room, I went to her roommate for suction. I washed my hands; I went to her (R1). She (R1) was unresponsive and pale, no vital signs at all. There was no alarm going on. She was disconnected from her vent. The [NAME] was disconnected and close to her trache. I did not hear anything. I did not hear any alarm prior. R1's Ambulance Report dated [DATE] recorded: Dispatched to a nursing home for cardiac arrest. Upon arrival the crew found staff doing CPR and an AED (automated external defibrillator) on the patient (R1) with no shock advised. The staff said the patient (R1) was last seen normal around 0200 (2 AM) and was found in her current state around 0415 (4:15 AM). They found her with the ventilator disconnected and no alarms sounding and they started CPR. No shock was ever given. The crew took over CPR efforts.CPR continued for roughly 18 minutes until a palpable pulse was felt. The patient was prepared for transport. Hospital was called and an abbreviated report was given for the cardiac arrest alert. Transport continued with the patient losing a pulse again. CPR restarted for about 4 minutes, and a pulse was again felt but lost after about 1 minute. CPR continued again as the crew arrived at hospital. Patient care was transferred to the nurse in room [ROOM NUMBER]. The following vitals were recorded by ambulance: 4:20 AM - HR (heart rate) 0; RR (respiratory rate) 0; cardiac rhythm was asystole4:39 AM - HR 83; rhythm regular; sinus rhythm; RR 184:48 AM - BP 83/52; HR 129; rhythm regular; sinus tachycardia; RR 164:50 AM - HR 0; RR 14 On [DATE] at 9:36 AM, V11 (Ambulance Crew) was interviewed regarding R1's condition on [DATE] upon arrival on scene. V11 replied, We got on scene around 4:20 AM, she was in cardiac arrest, staff were doing CPR on her. No pulse, no breathing, no heart electrical activity. They had their AED hook up and there was no shock given. They said they never gave a shock and machine stated no shock given. Usually, when it's not advising shock, patients are in asystole or in some other rhythm that would not advised AED to do the shock. We took over their CPR, we hooked her on the monitor. The first rhythm was asystole, no pulse, no heart activity. We started CPR manually then we put the chest compression device on her. According to our report, after 18 minutes of CPR, we felt pulse, we stopped CPR. We prepared her for transport to the hospital. And then it looked like we lost the pulse again when she got into the ambulance, we started CPR again. For four minutes, we got pulse again and lost it again. At the time, we arrived at the hospital, CPR is still ongoing, and we transferred the care to hospital staff. R1's hospital records dated [DATE] recorded in part but not limited to the following:Physical exam - HR none, RR noneGeneral: unresponsive without purposeful spontaneous movements, unresponsive to voice or painful tactile stimulus. HEENT (Head, Ears, Eyes, Nose, Throat): pupils fixed and dilated bilateralCardiovascular: absent heart sounds; no palpable carotid pulse bilateralPulmonary: mechanical breath sounds, no rise/fall of the chest, trach in place with significant discharge Extremities: cool dry to touch throughoutNeuro: GSC (Glasgow Coma scale) 3, unresponsive to voice/touch/painful stimulusEmergency Department (ED) Course: Chief complaint - cardiac arrest following disconnection from ventilatorBrief history: The patient, a [AGE] year-old, female, was found disconnected from her ventilator at approximately 4:15 AM without a pulse. AED was applied and it did not recommend defibrillation. NH (nursing home) staff started CPR. The last known well time was 2:00 AM. Upon discovery by paramedics, she was in asystole, and CPR was continued. The patient experienced brief return of spontaneous circulation (ROSC) with a BP of 80s/50s but repeatedly lost pulses. Initial rhythm here was asystole, with subsequent pulseless electrical activity (PEA). Epinephrine was administered, along with bicarbonate and calcium (when she had PEA). Her tracheostomy tube was suctioned. She was also given 1 liter bolus. Accucheck was 170. She had brief ROSC here but lost pulses shortly after. Despite these efforts, the patient remained in asystole for the majority of the resuscitation attempts. Time of death: 5:18 AM. Diagnosis:1.Cardiac arrest2. Cardiac asystole3. Chronic respiratory failure requiring continuous mechanical ventilation through tracheostomy. On [DATE] at 12:26 PM, V8 (Lead RT) was asked to show surveyor how ventilator alarms functioned. V8 verbalized, The whole second floor is the vent unit. The vent alarms make sounds when resident yawns, cough or move. The alarm is programmed by adjusting high and low pressures depending on resident. Low is 9/15 and high depends on resident, should be 20% of baseline. If it is disconnected, it will always alarm regardless of the setting. If it doesn't alarm, the vent might be faulty. It is a ventilator, it is super sensitive. Every vent has disconnection alarm. Every ventilator is connected to the wall and connects to outside by the door and hallway so alarm can be heard on the floor. The alarm lights up in the hallway for vent alarms. At this time, V8 triggered a vent alarm. The call light was turned on and vent alarms in the hallway also turned on. The alarm is heard throughout the vent unit. There are three vent alarms in the hallway: one on each side of the nurses' station, and one at the end of the hallway by room [ROOM NUMBER]. There is also a call light system at the nurses' station to show which room the call light was triggered. On [DATE] at 11:19 AM, surveyor and V8 reviewed the alarm logs in R1's ventilator called VOCSN (Ventilation, Oxygen, Cough, Suction, Nebulizer). V8 stated that the time in the log is one hour ahead as programmed. Upon review of VOCSN manual, under multi-view notes, the multi-view time is calculated backwards so that event times are relative to the most recent setting. This approach ensures the continuity of graphed and trended data in Multi-View reports; even though through time zones, daylight savings or other changes to the Date and time controls on VOCSN. R1's Multi-view usage report dated [DATE] to [DATE] revealed the following: 1/22 03:38:06 - High Inspiratory Pressure Alarm Triggered1/22 03:38:08 - High Inspiratory Pressure Alarm Resolved1/22 03:39:22 - Low Minute Volume Alarm Triggered1/22 03:39:25 - Low Minute Volume Alarm Resolved1/22 04:03:53 - Low Inspiratory Pressure Alarm Triggered 1/22 04:03:54 - Low Inspiratory Pressure Alarm Resolved1/22 04:04:02 - Low minute volume alarm triggered1/22 04:04:12 - Low minute volume alarm resolvedFrom 3:38:06 to 3:39:25 (real time 02:38:06 AM to 2:39:25 AM) - high inspiratory pressure and low minute volume alarms were triggered alternating with high inspiratory pressure alarm resolved and low minute volume alarm resolved. From 04:03:53 to 04:03:54 (real time 03:03:53 AM to 03:03:54 AM) - low inspiratory pressure alarm was triggered, resolved. From 04:04:02 to 04:04:12 (real time 3:04:02 AM to 3:04:12 AM - low minute volume alarm was triggered, resolved. There was no documentation indicating nurses or RTs responded to the triggered alarms. R1's progress notes did not show any documentation that she was assessed, and ventilator machine was evaluated due to on/off alarms between 2:38 AM to 3:04 AM. At 3:55 AM, she (R1) was found unresponsive, pale and disconnected from vent. On [DATE] at 12:00 PM, V8 was asked regarding R1's alarm logs. V8 verbalized, High pressure alarm means secretions, there's something in there that needs to be removed. The volume and pressure given by the vent is increased in that closed circuit due to secretions, obstruction, anything in the way getting the air to be delivered to the patient, like coughing or repositioning and airway is not patent. Low pressure alarm means the volume that is supposed to be delivered is lower. Secretions blocking the airway can be a cause, so suction patient, remove secretions and volume delivered. Pressure alarm resolved means patient coughed, then stop, resolved on its own, patient may need suction. Based on the alarm logs, her machine produced an alarm. Looking into her alarm logs, it did alarm. It triggered an alarm then stopped alarming. Staff need to check the patient (R1) and assess what is going on. Do not ignore on and off alarms. We have to physically go to the room and check the patient. The alarm is working, it's hard to ignore the alarm and it's the purpose of the alarm, to resolve the issue. Generally, we check residents on vent and if not every two hours, often more than every hour. We also rely on ventilators, so we check it physically and make sure all pieces are together and connected. Everyone is mandated to answer all alarms, maybe not address the issue but in tune with the alarms.On [DATE] at 1:21 PM, V10 (Nurse Practitioner, NP) was interviewed regarding R1. V10 verbalized, She is non-verbal; opens eyes; unresponsive to any stimuli; quadriplegic, unable to move; dependent on ventilator. Staff should do rounds on her every two hours and as needed. If vent alarm is triggered, staff need to get up and physically check resident (R1); perform trache care, oral care, suctioning, assess while providing care; monitor vital signs; medication administration is vital, making sure gtube is running and give water flushes; turningevery 2 hours and making sure brief is clean and dry. I was called in the morning that she (R1) was found pulseless, they did CPR and that she left with paramedics. They told me that she was stable and found her pulseless and unresponsive, they did code her and left with paramedics to hospital. She was there and she passed away. The nurse did not tell me that her vent was disconnected. They did not tell me. When she was found pulseless and unresponsive, her organs start to shut down, if the vent is not connected to what she was found to be, she would asphyxiate because there is no oxygen reaching her airway because she cannot breathe on her own. If she is disconnected from the vent, the vent will alarm, any alarm heard, staff need to respond immediately to the alarm. On [DATE] at 3:15 PM, V12 (Vice President of Respiratory Services) was asked regarding staff training on responding to ventilator alarms. V12 stated, V8 and me are responsible for providing in-services on RTs and nurses annually and on orientation. Prior to start working in the vent unit, staff need to have an orientation. Second floor is the only vent unit in the facility. Currently, we have 19 residents on vent and trache - 12 vents and 7 traches. We do in-services on suctioning, responding to vent alarms, trache care and suctioning, oxygen. With responding to vent alarms, RTs and nurses should respond to vent alarms right away. They have to look at the residents, if there is something wrong with the vent, they have to call RTs. Make sure residents are okay and all lines are connected. On a ventilator-dependent resident became disconnected from the trache, the vent will alarm. There are different high levels of alarm, if the alarm is triggered and then resolved constantly, it is a priority alarm. Regardless of what the alarm is, staff need to check the residents immediately. And staff are in-serviced on responding to the alarm. The alarm is so loud, made on purpose. On [DATE] at 2:33 PM, V16 (Medical Director) was interviewed regarding R1 and ventilator alarms. V16 replied, They informed me that she (R1) was at the hospital that she was unresponsive, and she passed away. She was on ventilator 24/7. She cannot breathe on her own. Any patients who are ventilator-dependent when disconnected from their vents cannot breathe. When disconnection from vent occurs, the alarm will go off, RT or nurses should go to patient and check what was going on and intervene. If patient's vent has issue, alarm has to go off, care team should see patient. Check for any disconnection and connect the circuit. Evaluate patient immediately. Address, evaluate, understand and act upon. All staff, especially RT, nurses or whoever is in charge of patients should respond to any alarm. On [DATE] 1:26 PM, V2 was interviewed regarding expectations on staff related to respiratory care and ventilator alarms. V2 stated, Staff should follow our policies and procedures; be aware of the residents' condition; make sure there are no alarm sounding and respond to vent alarms immediately. Make sure residents on ventilators are positioned properly and everything is connected properly. V3 was also interviewed on [DATE] at 1:30 PM regarding respiratory care and ventilator alarms. V3 replied, Staff need to use their critical thinking skills; be familiar with patient's condition; respond to alarms right away, any alarm like call light or vent alarms. All staff, including CNAs to respond to alarms and report to nurses and RTs. Facility's policy titled Mechanical Ventilation dated [DATE] documented in part but not limited to the following:Policy:All residents on mechanical ventilation will be monitored by respiratory therapist every shift and PRN. Ventilator alarm settings:Respiratory therapists and nurses are responsible for responding to ventilator alarms. The manufacturer's manual for R1's ventilator (VOCSN) documented in part but not limited to the following: AlarmsA VOCSN alarm will activate whenever the device detects a condition that requires clinician or caregiver attention. Alarms will generate an audible tone, and/or a blue, yellow or red alert banner across the top of the VOCSN screen. VOCSN has three alarm priority categories:Alarm priority: HighVisual indicator: red bannerAuditory indicator: 10 tones every 3 secondsClinician or caregiver response: Requires immediate clinician or caregiver response.Alarm priority: MediumVisual indicator: yellow bannerAuditory indicator: 3 tones every 7 secondsClinician or caregiver response: Requires prompt clinician or caregiver response.Alarm priority: LowVisual indicator: blue bannerAuditory indicator: no auditory indicatorClinician or caregiver response: Requires clinician or caregiver response.Alarm conditions and settingsThe high pressure alarm activates when the monitored airway pressure exceeds the set high pressure alarm limit for more than the number of consecutive breaths set with the High pressure Delay control. Recommended action: Monitor the patient closely and check for reduced patient lung compliance during volume ventilation. Check (brand name) circuit for occlusions. This is a high priority alarm.The low minute volume alarm activates when the monitored minute volume falls below the set low minute volume alarm limit. Recommended action: Monitor the patient closely to ensure adequate ventilation therapy is delivered. Check the (brand name) circuit for leaks or disconnection. During pressure-control ventilation, check the patient for reduced lung compliance or airway occlusion.NOTE: The Patient Circuit Disconnect alarm may not activate with every disconnect condition. (Name of company) recommends using the Low minute Volume, Low Inspiratory pressure and apnea alarms in addition to the Patient Circuit disconnect alarm to ensure (brand name) circuit disconnections are detected. The low inspiratory pressure alarm activates when the monitored peak inspiratory pressure falls below the set low inspiratory pressure alarm limit. Recommended action: Check the (brand name) circuit for leaks or disconnection. Monitor the patient closely to ensure adequate ventilation therapy is delivered. This is a high priority alarm. Responding to Alarms: The VOCSN operator must be capable of responding to alarm conditions and promptly performing the necessary corrective actions. R1 had low minute volume and low inspiratory pressure alarms per ventilator alarm logs. The Immediate Jeopardy that began on [DATE] was also removed on [DATE] when the facility took the following actions to remove the immediacy.Corrective Actions Taken:On [DATE] at 3:55 AM, V5 noted R1 unresponsive and disconnected from vent. V4 was called. R1 was found pale, no breathing noted, high quality CPR initiated, code blue called, emergency medical services were called. CPR continued until EMS arrived and transferred out to the hospital. These were verified with V4 and V5 during interviews and per review of hospital records and progress notes. 2. All 11 ventilator-dependent residents were checked for proper connection and alarm function. This was verified with V12 and through record review of the code blue debrief documentation conducted on [DATE] by V12. 3. Identification of other potentially affected residents and action: Resident with an open airway; Resident utilizing a ventilator. This was verified with V12 and through record review of the code blue debrief documentation conducted on [DATE] by V12. 4. All ventilator-dependent residents were checked for proper connection and alarm function. This was verified with V12 and through record review of the code blue debrief documentation conducted on [DATE] by V12, and in-services provided to staff on [DATE]. This was also verified through observation on [DATE] at 10:15 AM on R5, R7, R8 and R9's ventilators. 5. All ventilators were checked, ensuring all maintenance was performed as required. This was verified with V1and V20 (Maintenance Director) and per record review of facility's code blue debrief documentation on [DATE]. 6. All ventilator-dependent residents are checked by the assigned RT for proper connection and alarm function every 2 hours and PRN. These checks are documented once per shift. This was verified with V2 and V3 and per record reviews of audit tools from [DATE] to current. 7. Staff education was conducted by the ADON, lead RT, Regional Nurse Consultant and shift supervisor. This was verified with V3, V7 (Licensed Practical Nurse, LPN); V13 (RN) and V12; and per review of in-service on Respiratory Unit Care Guidelines dated [DATE]. 8. All staff assigned to the respiratory unit received education. Staff not on site for education were contacted by telephone and received verbal education. They will sign in service education forms before the start of their next shift. This includes PRN staff. This was verified with V1 and V3 and per review of in-service on Respiratory Unit Care Guidelines dated [DATE]. The facility does not use an agency for the respiratory unit. This was verified with V1 that facility does not use agency staff. 9. The facility has implemented a monitoring process conducted by the respiratory therapist to randomly audit ventilator residents to ensure ventilator settings, connections and alarm functionality are assessed after care activities that could disrupt the ventilator circuit. Ongoing every shift for 4 weeks. This was verified with V2, V3 and V8 and per review of audit tools from [DATE] to current. 10. The facility implemented observation audits of ventilator-dependent residents for secure connections. This was verified with V3 and per review of audit tools from [DATE] to current. This was also verified through observation on [DATE] at 10:15 AM on R5, R7, R8 and R9's ventilators. 11. Director of Nursing or designee will conduct direct observation in the respiratory unit to ensure prompt response to alarms at random shifts. This was verified with V1, V2, V3 and V18 and per review of audit tools from [DATE] to current. 12. Director if Nursing or designee will conduct direct observation of staff to ensure residents with an open airway are repositioned in bed appropriately and carefully to prevent interruption of respiratory tubing. This was verified with V1 and V2 and per review of audit tools from [DATE] to current. 13. Audits will be conducted 5 times a week for 2 weeks for all residents with open airway then weekly for 4 weeks. This was verified with V1, V2 and V3; and per review of audit tools from [DATE] to current. 14. Results of the audits will be presented to the QAPI committee for recommendations of further auditing and actions as appropriate. This was verified with V2 and per record review of all audits from [DATE] to current. 15. Code blue debrief is completed, and the action plan is discussed and approved by the Ad-Hoc committee. This was verified with V1 and V2 and per record review of all audits from [DATE] to current.

Based on interview and record review, the facility failed to ensure that a resident received care and services in accordance with professional standards of practice to promptly intervene, monitor, and escalate treatment for severe hypoglycemia for a resident. This failure applied to one (R1) of three residents reviewed for nursing care and resulted in R1 experiencing prolonged hypoglycemia of over two hours with decreased responsiveness, requiring emergent hospital transfer. R1 subsequently expired at the hospital the same day.This failure was identified as an Immediate Jeopardy. The Immediate Jeopardy began on November 18, 2025. V1 (Administrator) was notified of the Immediate Jeopardy on December 17, 2025 at 1:07PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on December 18, 2025, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. Findings include:R1 was a [AGE] year-old male who originally admitted to the facility on [DATE], discharged to the hospital on [DATE], and later expired. R1 had multiple diagnoses including but not limited to the following: anemia, ESRD dependence on dialysis, type II DM, CHF, colitis, pleural effusion, adult failure to thrive, and deep vein thrombosis.R1 expired at the hospital on [DATE]. Hospital record documents that upon arrival to the hospital at 10:31AM, R1 was found to be: desaturating into the 80s and placed on a non-rebreather at 15L. R1 was intubated and sedated at this time.On 11/18/2025, R1 experienced a hypoglycemic episode that was identified at 6:50AM by V6 (Former Licensed Practical Nurse).According to vital signs flowsheet report and progress notes, R1 experienced the following Blood Glucose levels and interventions on 11/18/2025:At 6:50AM, R1 was assessed by V6 to have a blood glucose of 42 mg/dl. V6 administered an emergency dose of Glucagon at this time.At 7:20AM, V6 rechecked R1's blood glucose to be at 43 mg/dl. V6 administered another emergency dose of Glucagon and apple juice was given to R1.At 7:30AM, R1's blood glucose was checked to be at 46 ml/dl. At this time V6 endorsed and gave report to day shift nurse, V5 (Licensed Practical Nurse).At 8:45AM, R1's blood sugar was checked to be at 52 mg/dl. V5 administered another emergency dose of Glucagon.At 9:20AM, R1's blood sugar was checked to be at 50 mg/dl. At this time, R1's vitals were checked, and it was noted that R1 was having labored breathing and decreased respirations. Per documentation, V7 (Nurse Practitioner) was notified and ordered to send R1 to the hospital via 911.At 9:23AM, R1's blood glucose was checked to be at 48 mg/dl.At 9:30AM, R1 left the facility with paramedics.Fire Department Field Care Report dated 11/18/2025 shows team was called to the scene for R1 having a diabetic problem. R1 was found in a seated position on his bed, unresponsive, head tilted forward, non-rebreather on. Staff states that R1 is normally alert and oriented x 4. Staff states R1 blood glucose was 42 at 7:00AM. Staff gave one dose of glucagon at that time. Staff rechecked R1's blood glucose at 9:00AM and found that it was still low at 48 mg/dl. Then called 911.It is to be noted that there is no documentation that the physician or the nurse practitioner was notified prior to 9:20AM. It is also to be noted that R1's blood glucose levels remained under 70 ml/dl for estimated two hours and thirty minutes before the nurse practitioner or 911 was called.On 12/16/2025 at 12:05PM, V6 (Former night LPN) said around 6:45AM, I went into R1's room. I noted R1 was not at his baseline, and I had to vigorously shake him to get him to arouse. I took R1's vitals and noted a blood glucose level of 42 mg/dl. I administered Glucagon at this time. I rechecked a bit later and noted his blood glucose level did not rise much. I then administered another dose of Glucagon.At this point, V5 (Morning LPN) arrived and gave him some apple juice, which he was able to drink. My understanding was that V5 was going to monitor R1 and I left the facility.On both 12/15/2025 at 11:25AM and 12/17/2025 at 11:10AM, V5 was interviewed. V5 said I arrived to my shift on 11/18/2025 between 7:00-7:30AM. I sat with V6 at the nurses' station and received report. V6 had mentioned that R1 was experiencing low blood glucose. After report, V6 and myself went into R1's room. No one was in R1's room when we arrived.We checked R1's blood glucose and I remember it was low, definitely below 50 mg/dl. We gave glucagon and apple juice which R1 drank. I rechecked a couple times, but it never got above 60 ml/dl. I gave the glucagon again and noted that he was having some abdominal, labored breathing. At this point, I hooked him up to the continuous vital monitor and noted his respirations were low. I called V3 (Assistant Director of Nursing) to help assist.On 12/15/2025 at 11:50AM, V3 said V5 called myself and another nursing supervisor to the floor to help assist. I would estimate that this was between 8:30AM-9:00AM. V5 said that R1's blood glucose was low and that she had given him Glucagon. We assessed R1 to not be at his baseline. R1's oxygen saturations were very low and they had him on a non-rebreather mask, receiving 25 liters of oxygen. At this point, we called 9-1-1 to send him out to the hospital.On 12/17/2025 at 10:05AM, V7 (Nurse Practitioner) said hypoglycemia to me, is anything below 80 mg/dl. If a resident is experiencing hypoglycemia, my expectation would be that the nursing staff offer juice to the resident if they are able to take food by mouth. If they are unable to do so or the blood glucose is very low, they should be given glucagon. They should continue to monitor the resident and the blood glucose. After fifteen minutes, if the blood glucose did not rise, they can give another dose of glucagon. My expectation would be for the nursing staff to immediately assess the patient, give the glucagon, and notify me as they monitor the resident. I should be notified of any resident that is experiencing hypoglycemia. I would also expect for a staff member to be with the resident at all times. V7 said, on 11/18/2025, I was notified by V5 that R1 was experiencing low blood glucose and that she had already given glucagon. She also said that at this time R1 was in respiratory distress. I told her to call 9-1-1 and send him to the hospital.On 12/15/2025 at 1:35PM, V2 (Director of Nursing) said V6 (former LPN) was terminated due to failing to follow our facility protocol. V6 should have notified V7 (Nurse Practitioner) right away when she noted R1 had low blood glucose, instead she endorsed it to V5 (LPN) when she came on her shift.Employee Disciplinary Action dated 11/18/2025 shows V6 received disciplinary action and was ultimately terminated for failure to follow MD/NP orders and notify MD/NP of change of condition.On 12/17/2025 at 2:37PM, V16 (Medical Director) said I would expect the nursing staff to promptly notify the attending upon any resident having a blood glucose level of 70 mg/dl or below.The ASCP (American Society of Consultant Pharmacists) hypoglycemia protocol, primarily for older adults in long-term care, uses the Rule of 15: if blood glucose (BG) is <70 mg/dL and the person can swallow, give 15g of fast-acting carbs (like glucose tabs/gel, juice), recheck in 15 mins, and repeat until BG >70 mg/dL; then provide a snack with carbs/protein, and for severe cases (unconscious/unable to swallow), administer glucagon and call 911. This protocol helps staff act without immediate physician orders in emergencies, following American Diabetes Association (ADA) guidelines. This protocol originated May 2023 and may be implemented without a physician's order.Facility Policy titled Hypoglycemia Management with last revision date of 11/2025 states in part but not limited to the following: Residents experiencing hypoglycemia (blood glucose below 70 mg/dl with or without symptoms) will receive prompt intervention. Treatment and Interventions: Blood Glucose <70 ml/dl and resident is conscious and able to take nutrition orally: Immediately give 15 grams of carbohydrates, staff to remain with resident at all times, repeat blood glucose and re-treat every 15 minutes until blood glucose is > 70mg/dl. If blood glucose <70 mg/dL and resident is unable or unwilling to consume nutrition orally: Immediately give ready to use glucagon. Staff to remain with resident at all times. In 15 minutes if the resident is not able or willing to consume nutrition within 15 minutes, give another dose of glucagon, and call for emergency help, i.e. 911.Facility Policy titled Change of Condition with last revision date of 2/2025 states in part but not limited to the following: The nurse will notify the resident's attending physician or physician extender when: there is a significant change in the resident's physical, mental, or psychosocial status; there is a need to alter the resident's treatment significantly; and it deems necessary or appropriate in the best interest of the resident. The nurse will record in the resident's medical record any changes in the resident's medical condition or status.The Immediate Jeopardy that began on 11/18/2025 was removed on 12/18/2025, when the facility took the following actions to remove the immediacy. On 12/18/2025, the survey team verified by observations, interviews, and record review, that the facility implemented the following to remove the immediacy.The facility abatement plan includes the following: TaskActionStatus (ongoing or completed with date of completion)Responsible PartyAction taken for affected resident.1) Juice was provided to the resident to improve the blood glucose level2) Glucagon was administered3) Blood glucose monitoring was performed4) NP was notified and resident transferred to ER via 9115) R1 no longer resides in thefacility.6) 1:1 education was provided to the day shift nurse and night shift supervisor who worked on 11/18/25 regarding hypoglycemia protocol, change of condition policy, following physician orders, and emergency response associated with severe hypoglycemia.7) The night shift nurse whoworked on 11/18 is no longer employed by the facility.11/18/25 12/15/2025 DONIdentification of other potentially affected residents and action1) Residents who require blood glucose monitoring can potentially be affected2) DON/designee conducted a whole-house audit of residents who require blood glucose monitoring to ensure blood glucose results are within the ordered parameters, and if physician / NP is notified if the results are outside the parameters. As a result of the audit conducted, no newfindings were identified.12/15/25DON/ADON TaskActionStatus (ongoing or completed with date of completion)Responsible Party 3) Residents who are at risk for hypoglycemia (residents with diagnosis of diabetes, receiving insulin) were reviewed to ensure the plan of care includes a physician order for parameters of blood glucose level to monitor signs and symptoms of hypoglycemia, administer interventions for treatment of hypoglycemia, and physiciannotification. Systemic measures to prevent recurrence1) Staff education was conducted by the DON, Regional Nurse Consultant and shift supervisor. Education included: Notification of a change in condition Medical emergency procedure associated with hypoglycemia Following the physician's orders Hypoglycemia Protocol All licensed nurses received education prior to working their next scheduled shift. Staff not on site for education were contacted by telephone and received verbal education. They will sign in-service education forms at the time of their next shift. This includes PRN staff.Understanding of the in-service content was evaluated at the time of in-service through questions and answers.12/15/2025Education was initiated on 12/15/2025 and completed on 12/15/2025DON/ Nurse Consultant/ Shift supervisor The facility does not use an agency for licensed staff.One staff member is out of the country and unable to receive education. This staff member will be educated at thetime of return to work. TaskActionStatus (ongoing or completed with date of completion)Responsible PartyPerformance effectiveness and monitoring (must include review by QA Committee) Director of Nursing or designee will audit resident records to ensure prompt notification to physician/ NP of an episode of hypoglycemia (change in condition) and following the physician's orders for notification of blood sugars outside of established parameters. Director of Nursing or designee will review the clinical record to monitor staff response to residents with signs and symptoms of hypoglycemia, monitor residents experiencing hypoglycemia, including severe hypoglycemia, administer interventions for treatment of hypoglycemia, and when emergency transport (911) and the medical provider are notified. Audits will be conducted 5 times a week for 2 weeks for all residents with blood glucose monitoring orders. Audits will be conducted weekly for 4 weeks for a sample of 10% of residents with blood glucosemonitoringAudits initiated 12/16/2025.DON/designee TaskActionStatus (ongoing or completed with date of completion)Responsible Party Results of the audits will be presented to the QAPI committee for recommendations of further auditing andactions as appropriate. Ad-Hoc or Full QA committee meetingRoot cause analysis is completed, and the action plan is discussed and approved by the Ad-Hoc committee.Medical Director: [NAME] Administrator: [NAME] DON: [NAME] ADON: [NAME] RNC: [NAME] 12/15/202512/18/2025Medical Director Administrator DONADON RNC

Based on observations, interviews, and record reviews, the facility failed to document accurate meal intakes, offer alternative meal options, and notify the physician or nurse practitioner of significant weight loss. Additionally, the facility failed to implement the dietitian ' s recommendations and follow the physician ' s orders to increase Remeron for weight management. This deficient practice affected two of the seven residents (R62 and R103) reviewed for nutrition and unplanned weight loss prevention. As a result, Resident R62 experienced a 10% unplanned weight loss over a six-month period. Findings include: On 4/8/25 at 12:10 PM, R62 was observed in dining room for lunch meal. Staff were observed setting up R62's tray. R62 was observed replacing the cover on plate and self propelling wheelchair out of dining room. On 4/8/25 at 12:15 PM, R62 was observed self propelling wheelchair into dining room. R62 lifted the cover over plate then replaced cover and left dining room. Staff were observed removing R62's tray and place on the cart for dirty plates. R62 did not consume meal. On 4/9/25 at 11:15 AM, V7 RD (registered dietitian) stated that V7 audits all resident weights each month. V7 stated that V7 will request a resident be re-weighed if there is a change in weight of 5 or more pounds in one month. V7 stated that residents with weight loss are monitored and discuss during morning meeting with the interdisciplinary team. On 4/10/25 at 1:00 PM, V15 LPN (licensed practical nurse) stated that the CNAs (certified nurse aides) document the amount eaten for each resident in their POC (point of care) charting. V15 stated that the CNAs will inform the nurse if the resident does not eat a meal. When questioned if V15 was aware that R62 did not eat lunch on 4/8, V15 did not respond. R62's POC charting, dated 4/8/25, does not note amount eaten for lunch was documented. R62's medical record does not note any documentation on 4/8/25 related to R62 not eating lunch. R62's POS (physician order sheet) notes an order for LCS (Low Concentrated Sweets) diet, Regular texture, Regular/Thin consistency. R62's weight documentation: On 4/9/25, R62's weight was 125 pounds On 3/10, R62's weight was 128 pounds On 1/8, R62's weight was 130.6 pounds On 10/4/24, R62's weight was 139 pounds R62's weight documentation notes 10.07% weight loss for 6 months. V7 RD (registered dietitian) note, dated 4/10/25, notes significant weight loss review. Current weight record for 4/9/25 recorded at 125 pounds. Weight over 1, 3, and 6 months are as follows: 1 month - 3/10/25 - 128(2.3%), 3 months - 1/8/25 - 130.6(4.3%), and 6 months - 10/4/24 - 139(10.1%). Significant weight loss at 6 months, which is unplanned/unavoidable and likely related to a combination of variable oral intake at mealtimes and behaviors associated with her diagnosis of dementia. Recommendations were to have a psychiatric consult placed as resident has the tendency to wheel herself around the unit throughout the day, and sometimes during mealtimes, in which case she may miss her meal. Nurse practitioner was also informed of recommendations. BMI (body mass index): 22.1 - underweight; desirable BMI for age >65: 23-29.9. Diet: Regular, LCS, thin liquids. Double portions and snack at lunch and dinner. Supplement(s): Supercereal at breakfast and Med Pass 120 ml (milliliters) three times daily. R62's medical record notes R62 was last seen by V7 on 12/4/24. This facility's weight maintenance policy, revised 03/2022, notes all significant, unplanned, or trending weight changes must be investigated by the facility. The director of nursing will refer all concerns and recommendations to the appropriate department for action. The director of nursing or designee will ensure physicians and resident representatives are informed of significant or trending weight fluctuations or concerns regarding a change in the resident's nutritional status. 39340 R103 was admitted to the facility on [DATE] with a diagnosis of parkinsonism, dementia, and contractures. R103 progress notes dated 1/15/25: Registered Dietician follow up. Resident's weight has trended down x past 6 months, in which weight history and current nutritional interventions were discussed with Nurse Practitioner. Resident is receiving Super cereal at breakfast, Health Shake q meal, Pro-Stat Sugar Free 30 ml every day and Remeron 7.5 mg at bedtime, thus Nurse Practitioner was agreeable to increasing dose of Remeron to 15 mg q HS. R103's nurse practitioner progress notes dated 1/17/25: patient seen and examined. Reason for visit: Weight loss. dietician following discussed with dietician will increase Remeron to 15mg continue all interventions per dietician. On 4/10/25 at 10:29AM, V12 (Nurse practitioner) said she would expect her orders to be followed as ordered. V12 said any new orders are verbally relied to the nurse to put into the electronic computer system. V12 said Remeron would be ordered to help increase a resident's appetite with weight loss. On 4/9/25 at 11:13AM, V7(dietician) said he expects his recommendations to be followed unless the physician does not agree. V7 said he recalls speaking to the V12 (nurse practitioner) about increasing Remeron due to weight loss for R103. V7 said R103 body max index was 14.3 which is considered underweight. R103's current physician order documents. Remeron 15 mg. Give 0.5 tablet (7.5MG) orally at bedtime with a start date of 10/24/24. R103's medication administration record for January, February. March and April documents: Remeron 15 mg. Give 0.5 tablet (7.5MG) orally at bedtime. Facility policy physician orders revised 5/2017 documents: all residents medications, and treatments must be ordered by a licensed physician or nurse practitioner. Physician orders must be reviewed every 60 days. The nursing staff member who took the order or the one assigned to the resident is responsible to transcribe the order. On monthly basis, the physician orders will be reviewed for accuracy by nursing personal.

Based on observation, interview and record review, the facility failed to ensure low air loss mattress devices were on the correct weights setting for residents who are at risk in developing pressure ulcers. This failure has the potential to affect four (R28, R92, R116 and R168) out of four residents reviewed for pressure ulcer care in a final sample of 55 residents. Findings include: On 4/8/25 at 10:45AM, observed R92 in bed, on low air loss mattress set to normal pressure below 80. Setting confirmed with V4 (LPN). Record reviewed R92 weight record dated 3/10/25 is 105.6 lbs. On 4/8/25 at 10:47AM, observed R116 in bed, on low air loss mattress set to normal pressure between 210 to 250. Setting confirmed with V4 (LPN). Record reviewed R116 weight record dated 3/10/25 is 113.9 lbs. On 4/8/25 at 10:50AM, observed R28 in bed, on low air loss mattress is power off. Mattress deflated. Confirmed with V4 (LPN) that the low air loss mattress is deflated. V4 checked and tried to turn on, observed it is unplugged. V4 plugged the low air loss mattress and turned the power on. Low pressure light on and blinking. Per V4 it would take a while for the inflation. Setting placed between 120 to150. R28's recorded weight on 3/10 25 is 139.6 lbs. On 4/9/25 at 9:48AM, observed R92 in bed and in low air loss mattress set on normal pressure between 150 to 180. Setting confirmed with V4 (LPN). Record reviewed R92 weight record dated 3/10/25 is 105.6 lbs. On 4/9/25 at 10AM, observed R168 in bed, on low air loss mattress setting between 250 to 280. Setting confirmed with V4 (LPN). Recorded weight on 3/10/25 is at 247.8 lbs. On 4/10/25 at 9:57AM, V11 (Wound nurse) stated that they place residents in low air loss mattress because they are either with pressure ulcer or at risk for pressure ulcer injury, especially those who are high risk. Stated that R92 has no active wound but assessed as High Risk. R168 has no active wounds, and also assessed as high risk. R116 has no active pressure wound and assesses as high risk. That R116 has vascular wounds in lower extremities and on hospice. R28 has no active wound and assessed to be at high risk, V11 stated that the setting is set based on residents weights. And if there are changes in resident's weight, then the staff need to adjust the setting. I check and the other staff checks the setting and if the bed is in working order. If the low air loss mattress is not on and deflated, then the preventative measure would not be working. R92's Braden scale for predicting pressure sore risk dated 3/1/25 is 11 (High Risk). Care plan for potential skin breakdown/pressure ulcer with interventions of may use low air loss mattress for pressure reduction. R168's Braden scale for predicting pressure sore risk dated 3/14/25 is 13 (Moderate Risk). Care plan for potential skin breakdown with intervention of may use low air loss mattress for pressure reduction. R116's Braden scale for predicting pressure sore risk dated 1/14/25 is 13 (Moderate Risk). Care plan for potential skin breakdown/pressure ulcer. R28's Braden scale for predicting pressure sore risk dated 1/06/25 is 12 (High Risk). Care plan for potential for skin breakdown/pressure ulcer with intervention of may use low air loss mattress for pressure reduction. Alternating Pressure Air Mattress policy with a revision date of 5/17, reads in part: objective is to provide pressure relief. Pressure Ulcer Treatment and Management with a revision date of 5/`7, reads in part: Residents with pressure ulcers will have a physician's order for treatment. The plan of care will include the presence of the pressure ulcer and include the individual description of the treatment plan including: pressure relief, turning and repositioning, additional nutritional measure, need for assistance with mobility and range of motion. Resident with pressure ulcers will be determined to be high risk for pressure ulcer prevention and all components of the At Risk protocol will include: pressure relieving devices, nutritional support, and assistance with mobility including repositioning and ROM (Range of Motion) as outlined in the At Risk Protocol. Pressure Ulcer Prevention Protocol with a revision date of 5/18, reads in part: Resident will be assessed to determine their risk factors for pressure ulcer development. Resident will be assessed to determine their risk factor for pressure ulcers development, upon admission and at least quarterly thereafter. All beds in the facility will have pressure reducing mattresses unless pressure relieving mattresses are required according to resident's needs. Interventions necessary to maintain skin integrity or to promote healing will be incorporated into the plan of care based on each resident's individual needs and risks, which may include: Use of pressure reducing devices, such as pressure reducing mattresses, mattresses overlays, w/c cushioning devices if needed.

Based on observations, interviews, and record reviews, the facility failed to effectively supervise one resident on a thickened liquid diet from drinking a cup of thin liquids from another resident's meal tray for a resident assessed with mild to moderate risk for aspiration. This failure affected one resident (91) out of three reviewed for mechanically altered diets in a sample of 55. Based on observation, interview and record review, the facility failed to present a smoking policy that included the safe use and how the facility would supervise residents using electronic smoking materials and failed to complete quarterly smoking assessments. This affected four of four residents (R111, R61, R8, and R161) reviewed for smoking safety and supervision. Findings include: On 4/8/25 at 12:05 PM, staff was observed pouring thin liquid juice container, 120ml (milliliters) into a cup for R165 and placing the cup on her tray. 04/08/25 at 12:05 PM R91 was observed taking a cup filled with thin liquids off another resident's tray and drink from it. Resident consumed 100% of the liquid in this cup. At 12:15 PM, R91 was given her lunch tray, pureed diet with nectar thick liquids. On 4/10/25 at 10:00 AM, V12 NP (nurse practitioner) stated that mechanically altered diets are ordered for a reason. When informed that R91 drank a cupful of thin liquids, V12 responded that V12 didn't think R91 was able to feed or drink by herself. On 4/10/25 at 1:20 PM, 17 CNA (certified nurse aide) stated that R91 will reach for cups that are close by R91 and drink from cup. On 4/10/25 at 1:35 PM, V16 LPN (licensed practical nurse) stated that R91 has a behavior of reaching for cups nearby and drinking from the cups. R91's modified barium swallow study, dated 11/5/2020, notes R91 presented with a mild-moderate oropharyngeal phase dysphagia. Reduced safety with thin liquids due to premature spillage, impulsive sips, and delayed pharyngeal swallow response resulting in silent aspiration in slight amounts with thin liquids at the onset of the swallow and frequent deep penetration to the vocal folds with accumulating residue. Aspiration also noted after the swallow due to mild-moderate to moderate levels of thin residue spilling into the trachea after the swallow without sensation or ability to elicit a cough. No airway invasion noted with puree or mildly thickened liquids (nectar thick liquids). This facility's supervision of resident nutrition policy, dated 05/2017, notes nursing personnel are responsible for assuring that residents are served the correct dietary tray. 39340 R111 was admitted to the facility on [DATE] with a diagnosis of type II diabetes, hemiplegia affecting left side, major depressive disorder and peripheral vascular disease. R111's brief interview for mental status dated 2/22/25 documents a score of 14/15 which indicates cognitively intact. On 4/8/25 at 10:14AM, R111 was observed with smoking material in his room. R111 said he is a smoker and is able to smoke on the patio unsupervised. R111 smoking risk assessment dated [DATE] documents a score of 3 which indicates safe smoker. The facility was asked to present any other smoking assessments for R111. No other assessments were given to the surveyor. R111 medical record did not document any other assessments upon review. R111 current plan of care did not document any current smoking plan of care. On 4/10/25 at 9:42AM, V2(Vice president Operations) said smoking assessments are conducted on admission, quarterly, annual and with changes, V2 said the smoking assessments were not conducted until this morning and care plans were updated this morning. Smoking Policy 2/2017 documents: Resident's clinical record will be updated to reflect smoking status. Resident will be re-evaluated quarterly and annually thereafter unless circumstances warrant an off-cycle assessment related to a change in baseline, i.e change in cognition, change in physical functioning or behavioral concerns that may impact the safety and welfare of the resident or others. Care plans will be created/updated as necessary to reflect the resident's preference or needs. 41758 R61 R61 brief interview for mental status dated 3/24/25 documents a score of eight which indicates moderate cognitive impairment. On 4/8/25 at 10:33am, R61 who was assessed to be alert and oriented to person place and time, said he is a smoker and inhaled on his vape pen. On 4/9/25 at 4:10pm, V3 (don) said, R61 does not have a smoking assessment. R61 was supposed to quit smoking in September 2024. Independent smokers can hold on to their smoking material. V3 said, she was not aware R61 had a vape pen. R61's progress note dated 9/24/24 documents: former smoker. On 4/10/25 at 9:42AM, V2(Vice President Operations) said, smoking assessments are conducted on admission, quarterly, annual and with changes, V2 said, the smoking assessments were not conducted until this morning. Care plans were also updated this morning. R61's smoking and safety assessment dated [DATE] documents: Supervision, designated smoking location and smoking times are determined by facility policy. R61 use tobacco and vape products. Smoking Management care plan dated 4/10/25 documents: I (R61) desire to smoke. I have been assessed to determine safety factors. I am aware of the facility policy encompassing electronic, as well as tobacco-based products does not allow a resident to carry any smoking materials. Smoking is only allowed outside at designated times with proper distancing. I have been made of the rules and I voluntarily agree to follow all the rules. I acknowledge that smoking is a privilege and I agree to behave safely. Smoking Policy 2/2017 documents: Resident's clinical record will be updated to reflect smoking status. Resident will be re-evaluated quarterly and annually thereafter unless circumstances warrant an off-cycle assessment related to a change in baseline, i.e. change in cognition, change in physical functioning or behavioral concerns that may impact the safety and welfare of the resident or others. Care plans will be created/updated as necessary to reflect the resident's preference or needs. Those resident who have been assessed and determined to be an at risk smoker will be allowed to participate in the center's supervised smoking programs. These identified individuals will have smoking material made available to them when under direct supervision of a staff member. Individuals who smoke will smoke in designated areas only. R8's R8's smoking and safety assessment dated [DATE] documents: Supervision, designated smoking location and smoking times are determined by facility policy. R8 use tobacco. Balance problems while sitting and standing. Unable to extinguish tobacco or marijuana safely. Requires supervision to ensure tobacco extinguish properly. Resident has a brace on right leg from injury prior to admission. On 4/10/25 at 9:42AM, V2(Vice President Operations) said, smoking assessments are conducted on admission, quarterly, annual and with changes, V2 said, the smoking assessments were not conducted until this morning. Care plans were also updated this morning. Smoking Management care plan dated 4/10/25 documents: I (R8) desire to smoke. I have been assessed to determine safety factors. I am aware of the facility policy encompassing electronic, as well as tobacco-based products does not allow a resident assessed as compromised to carry any smoking materials. Smoking is only allowed outside, at designated times with proper distancing. I have been made aware of the rules and I voluntarily agree to follow all the rules. I acknowledge that smoking is a privilege and I agree to behave safely. I have been counseled concerning the innumerable hazards, health risks and complications associated with smoking. Smoking Policy 2/2017 documents: Resident's clinical record will be updated to reflect smoking status. Resident will be re-evaluated quarterly and annually thereafter unless circumstances warrant an off-cycle assessment related to a change in baseline, i.e change in cognition, change in physical functioning or behavioral concerns that may impact the safety and welfare of the resident or others. Care plans will be created/updated as necessary to reflect the resident's preference or needs. R161 R161's brief interview for mental status dated 1/13/25 documents a score of fifteen which indicates cognitively intact. R161's smoking and safety assessment dated [DATE] documents: Supervision, designated smoking location and smoking times are determined by facility policy. Product resident use: Tobacco, Marijuana and vape product not check. On 4/10/25 at 9:42AM, V2(Vice President Operations) said, smoking assessments are conducted on admission, quarterly, annual and with changes, V2 said, the smoking assessments were not conducted until this morning. Care plans were also updated this morning. On 4/11/25 at 11:30am, R161 who was assessed to be alert and orient to person, place and time, said, he smokes occasionally. Smoking Management care plan dated 4/10/25 documents: I (R161) have been assessed to determine safety factors. I am aware of the facility policy encompassing electronic, as well as tobacco-based products does not allow a resident assessed as compromised to carry any smoking materials. Smoking is only allowed outside, at designated times with proper distancing. I have been made aware of the rules and I voluntarily agree to follow all the rules. I acknowledge that smoking is a privilege and I agree to behave safely. Smoking Policy 2/2017 documents: Resident's clinical record will be updated to reflect smoking status. Resident will be re-evaluated quarterly and annually thereafter unless circumstances warrant an off-cycle assessment related to a change in baseline, i.e change in cognition, change in physical functioning or behavioral concerns that may impact the safety and welfare of the resident or others. Care plans will be created/updated as necessary to reflect the resident's preference or needs.

Based on observation, interview and record review, the facility failed to follow their Call Light policy. The facility failed to place the call light within reach for one resident (R40) of three residents reviewed for call light accessibility in a total sample of 55 residents. Findings include: On 4/8/25 at 1040AM observed R40 in bed, watching television. Mouth piece/puffer call light not within reach. Head of bed elevated and the puffer call light was above the head of bed, above her head and on right side facing the door area. R40 stated she cannot reach the call light because it is not close to her mouth. R40 unable to reach the call light, noted to have limited range of motion on her right arm. On 4/8/25 at 1043AM, confirmed with V5 (CNA). V5 Stated that staff usually placed R40's call light closer to her mouth. R40 is not able to reach and use her call light at this moment because of its placement. I will reposition her and place the puffer call light closer to R40. R40's Joint Mobility assessment dated [DATE], reads in part: Right shoulder with severe joint limitation with 0-25% available ROM (Range of Motion), right elbow with moderate to severe limitation with 25 to 50% available ROM, and right wrist with severe joint limitation with 0-25% ROM. On 4/9/25 at 11:30AM, V6 (Restorative Nurse) stated that R40 has a limited range of motion on her right arm, needs staff assistance for right arm range of motion. R40 would not able to use her call light if the call light is not position within her reach and by her mouth. Due to poor right arm range of motion R40 will not be able to reach the call light with her hand to place it closer to her mouth. Staff needs to make sure it is closer to R40's mouth so R40 could utilize the call light. Call light policy with a revision date of 6/21, reads in part: Functioning call light placed to where it is accessible to the resident.

Based on observations, interviews, and record reviews, the facility failed to follow its comprehensive care plans policy and accurately assess and revise care plans as changes in the residents' conditions dictate for three residents (R46, R49, and R91) out of three reviewed for care plans in a sample of 55. Findings include: On 4/9/25 at 12:00 PM, R49 was observed to have an electronic monitoring device on her left wrist. On 4/10/25 at 1:05 PM, V20 (MDS (minimum data set) coordinator) stated that this facility changed computer systems in October 2024. V20 stated that all care plans in the residents' current electronic medical record are up-to-date. V20 stated that care plans are important so that everyone is on the same page with the resident's care. V20 stated that a resident's care plan is updated when there is a change in resident's condition. V20 stated that care plans are reviewed quarterly, annually, and upon admission to this facility. V20 stated that care plans are reviewed with MDS. V20 stated that V20 is responsible for entering any new diagnosis that is identified. V20 stated that the interdisciplinary team participates and completes the appropriate portions of the care plan. R46: R46 was readmitted to this facility on 1/25/25 from the hospital. R46 returned with a new diagnosis of iron deficiency anemia . R46's medical records notes R46 had a quarterly MDS completed on 11/4/24 and 2/3/25. R46's care plan does not note a care plan was initiated related to the new diagnosis of iron deficiency anemia. R49: R49's POS (physician order sheet), dated 9/19/24, notes an order for an electronic monitoring device - check and record placement every shift. R49's medical records notes R49 had a quarterly MDS completed on 12/10/24 and 3/10/25. R49's care plan does not note a care plan was initiated related to wandering risk and use of electronic monitoring device. R91: R91's POS, dated 9/19/24, notes an order for regular diet pureed texture, nectar/mildly thick consistency, supercereal with breakfast. R91's medical records notes R91 had a quarterly MDS completed on 11/1/24 and 1/16/25. R91 also had an MDS for significant change on 3/14/25. R49's care plan does not note a care plan was initiated related to mechanically altered diet or behaviors of taking other residents drinks. This facility's comprehensive care plans policy, reviewed 04/2017, notes the comprehensive care plan will be developed with input from the interdisciplinary team, which includes at a minimum: attending physician, registered nurse responsible for the resident, nurse aide with responsibility for the resident, a member of food and nutrition services staff, to the extent practicable, the participation of the resident and the resident's representative, other appropriate staff or professionals in disciplines as determined by the resident's needs. Services are to be furnished to attain or maintain the resident's highest practicable well being, measurable objectives and timeframes, the resident's goals for admission and desired outcomes. Care plans are revised as changes in the resident's condition dictates.

Based on interview and record review, the facility failed to follow their radiology or other diagnostic ordering policy by not following physician orders to obtaining an x-ray for one resident (R60) for one of one reviewed radiology services. Findings include: R60 admitted to the facility on [DATE] with a diagnosis of anemia, type II diabetes, pain in left and right shoulder R60's nurse practitioner progress note dated 3/28/25 documents: history of shingles, neuropathy and neuropathic pain / left shoulder pain. patient wants another left shoulder x-ray done. One was done in the past and showed shoulder dislocation and patient refused to have it corrected. Will repeat x-ray. R60's physician order dated 3/28/25 document left shoulder x-ray. On 4/10/25 at 10:29AM, V12 (Nurse practitioner) said she ordered x-ray for R60 due to complaints of pain. V12 said she would expect the x-ray to be completed within a few days and was unaware the x-ray was not completed until after the surveyor requested the results on 4/8/25. V12 said she did receive the results and put in a referral for rehab specialist to see the resident and possible give a pain injection due to arthritis. On 4/9/25 at 1:02PM, V3(director of nursing, DON) said R60's x-ray was not completed as ordered. V3 said there was an error in placing the order and the x-ray was not completed until 4/9/25. V3 said when an x-ray order is placed it will usually be conducted within 24 hours. Facility policy or other diagnostic ordering policy dated 9/17 documents under objective: to provide or obtain radiology or other diagnostic monitoring in accordance with the orders of the physician, physician assistant or nurse practitioner. Upon receipt of the order, the nurse processing the order will notify the appropriate service provider.

Based on observations, interviews, and record reviews, the facility failed to follow its the posted infection control signage and don appropriate PPE (personal protective equipment) prior to entering one resident's room that is on enhanced barrier precautions and performing blood draw This affected one of one resident (R105) reviewed for infection control in a sample of 55. Findings include: On 4/9/25 at 9:45 AM, signage noting enhanced barrier precautions was noted on entry door to R105's room. On 4/9/25 at 9:45 AM, V8 (outside laboratory staff) was observed in R105's room on the left side of R105's bed leaning over R105 to draw blood from R105's right hand. V8 was not wearing gloves or gown while performing direct resident care. On 4/9/25 at 2:30 PM, V9 IP nurse (infection prevention nurse) stated that staff are expected to don gown and gloves prior to performing direct resident care for residents on enhanced barrier precautions. V9 stated that the outside laboratory staff are aware of this facility's infection control policy and are expected to follow it. V9 stated that V9 spoke with V8 regarding not wearing appropriate PPE (personal protective equipment) when performing blood draws for residents. V9 stated that V8 informed her that she is unable to feel the resident's vein when wearing gloves. V9 stated that it is not acceptable to not wear gloves. V9 stated that she is responsible for infection control and this will not be tolerated at this facility. R105's POS (physician order sheet) dated 1/23/25, notes enhanced barrier precautions: related to medical device, wound site, and history of C-Auris CRAB sputum, NDM of the urine and CRE urine and sputum and wound site. The enhanced barrier precautions signage notes all providers and staff must wear gloves and gown for high-contact resident care activities.

Based on interview and record review, the facility failed to prevent and protect a resident from resident-to-resident physical abuse. This failure applied to two of two (R1, R2) residents reviewed for abuse. Findings include: Facility reported incident (FRI) dated 10/11/2024 documents: R1 reported to the nurse that R2 slapped her in the face. R1 was noted to have a scratch to the left side of face. R1's face sheet dated 01/08/2025 documents that R1 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis history of Hypertensive heart disease, dyslipidemia, gastroesophageal reflux disease, chronic obstructive pulmonary disease, chronic kidney disease and depression. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 has a Brief Interview for Mental Status (BIMS) score of 9 (moderate cognitive impairment). 1/06/2025 at 12:05 PM V9 (Licensed Practical Nurse/LPN) said that R1 does have behaviors during her shift and speaks the same language as R1 and able to communicate well. R1 is alert but forgetful and has no aggressive behaviors. R1 experiences behaviors during the PM shift/sundowning such as crying and talking continuously. V9 (LPN) translated for R1 and said that R1 was using the restroom and was coming back to her bed when R2 got upset, slapped her face and left two red marks to the face. R1 said that the nurses were putting medication on her face but the scratch is healed and the roommate is no longer in the room. R1's nurses notes dated 10/11/2024 documents: R1 noted to have small red scratches on left side of the face, and order for bacitracin medication twice a day for 7 days. R2 is a female admitted to the facility on [DATE] with the diagnosis history of dementia, strokes, atrial fibrillation, end stage renal disease on hemodialysis, diabetes, depression, arthritis, heart failure, hypertension, and Hyperlipidemia. R2's Minimum Data Set (MDS) dated [DATE] documents that R1 has a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive impairment). 1/06/2025 at 11:55AM R2 was sitting at the edge of the bed and waiting for lunch, verbalized being tired and did not want to talk regarding the incident with R1. R2 said, I do not remember anything, leave me alone. 1/07/2025 at 3:00 PM V8 (Certified Nursing Assistant/CNA) said, I witnessed R1 and R2 fighting and R2 said that she had dialysis and was very tired and wanted to sleep but R1 was talking and talking, when R2 threw a cup of water on R1 and scratched her face. V8 said that R1 was upset that R2 had three sons visiting and was inside of the bedroom. R1 started to talk and R2 didn't understand R1 and they started to fight. It was the only time I have seen R2 getting aggressive and R1 is never aggressive. 01/07/2025 at 3:33PM V11 (Licensed Practical Nurse) said that R1 called and notified V11 that R2 hit R1's face with her hand. V11 stated that R1 and R2 were separated and one scratch was noted to R1's left side of the face. V11 notified supervisor and V1 (Administrator). V11 said that R2 was tired and wanted to go to sleep and R1 was talking nonstop. R2 got upset and had a fight with R1 and the language barrier between that made it worst. 01/06/2025 on 1:27PM V4 (Social Services Director) said that was not aware of any incident involving R1 and R2 because he was out town on vacation (10/09/2024-10/20/2024) and V3 (Assistant Administrator) and V1 were covering for him during that time. 01/07/2025 at 3:30PM V2 (Director of Nursing) said that R1 and R2 had no previous aggressive behavior and R2 was moved to the first floor and no aggressive behavior was noted for R2. R2 stayed on the first floor and returned to the fourth floor on 10/24/2024. V1 and social services were the ones responsible to evaluate and decide if resident is safe to return to the same unit prior to moving R2 with another resident. 01/07/2025 at 3:35PM V1 sad that R2 moved back to the unit after the interdisciplinary team met and social service completed an evaluation. Facility completed behavior assessment and monitor for R2's behaviors. V1 was not able to provide notes of the meeting or social services assessment. On 01/07/2025 at 3:35PM V1 (Administrator) presented policy titled: Facility Abuse Prevention Guidance (Revised October 2022), which reads: Policy Statement: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: -Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, and misappropriation of property. -Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines)

Based on observations, interviews, and record reviews, the facility failed to effectively supervise and ensure one resident was seated properly in wheelchair with feet on footrests or elevated off floor prior to transporting. This affected one of three residents' (R1) reviewed for safety. This failure resulted in R1 falling from the wheelchair sustaining a laceration to forehead requiring seven sutures and a left patella fracture. Findings include: On 10/12/24 from 11:20 AM until 12:40 PM R1 was observed sitting in wheelchair in the dining room. R1 was observed sitting with back against wheelchair back and holding a doll. R1 was able to feed self once her meal was set up for her. R1 was not observed shifting weight, leaning forward in wheelchair, or making any sudden movements. On 10/12/24 at 12:40 PM, V3 CNA (certified nurse aide) was observed transporting R1 to R1's room. R1's room is directly across from the nurses' station. V3 and V4 CNA were observed transferring R1 from wheelchair to bed. R1's wheelchair was placed next to bed. V4 placed a gait belt around R1's waist and drag pivoted R1 onto her bed. R1's legs were bent at the knees throughout transfer. R1 was not able to straighten legs to support R1's weight. R1's upper body was observed leaning far forward. R1 was totally dependent on V3 and V4 for transfer. R1's care plan, initiated 5/1/2015, notes R1 has risk or actual needs/symptoms related to Alzheimer's disease and dementia. Interventions include provide reminders for ADL (activities of daily living) and provide cues and supervision for ADLs every day. R1 falls care plan, initiated 5/1/2015, notes R1 is at high risk for falling related to decreased bed mobility and ambulation, Alzheimer's disease, dementia, muscle weakness, difficulty in walking, and multiple comorbidities. R1's falls risk assessment, dated 7/16/24, notes R1 is at high risk for falls. R1's OT (occupational therapy) evaluation, dated 6/25/24 notes R1 dependent for upper body dressing, transfers, and unable to stand and bear weight. R1's OT discharge summary, dated 7/25/24, notes R1 requires substantial/maximum assistance with upper body dressing. R1 requires substantial/maximum assistance with transfers from bed to wheelchair to bed. R1 is able to stand for 30 seconds with maximum assistance of two persons. R1 achieved maximum potential with OT and was discharged from skilled therapy. R1's MDS (minimum data set), dated 7/16/24, notes R1 with functional limitation in range of motion in both upper extremities. R1's cognitive status for daily decision making is severely impaired. R1's ADL care plan, initiated 8/6/2019, notes R1 is at risk for ADL decline related to generalized weakness and deconditioning. Interventions include transfers - R1 is dependent on staff for all transfers, use mechanical lift device for all transfers. Wheelchair - R1 requires substantial/maximum assistance for locomotion. R1 may require two person assist in periods of lethargy, weakness. On 10/12/24 at 12:40 PM, V3 CNA (certified nurse aide) stated prior to R1's fall, R1 was able to self-propel in wheelchair. V3 denied witnessing R1 lean forward in wheelchair or attempt to stand unassisted by staff. On 10/12/24 at 12:45 PM, V4 CNA stated prior to R1's fall, R1 was able to self-propel in wheelchair. V4 denied witnessing R1 lean forward in wheelchair or attempt to stand unassisted by staff. V4 stated prior to fall R1 was able to take a few steps with staff assistance. On 10/13/24 at 4:15 PM, V5 LPN (licensed practical nurse) stated on 8/17/24, V5 was in the resident room next door to R1's room. V5 stated when V5 exited room V5 observed R1 on the floor. V5 stated V6 CNA informed her R1 leaned forward and fell out of wheelchair. V5 stated R1 was able to stand while sitting in wheelchair but would sit right back down. V5 stated R1 was able to self-propel in wheelchair prior to the fall. On 10/14/24 at 12:13 PM, V9 CNA stated she was working on 8/17/24 evening shift when R1 fell . V9 stated prior to the event she was sitting at nurses' station charting on computer. V9 stated R1 is a two person transfer and she instructed V6 to let her know when she was ready to have her assist with transferring R1 to bed. V9 stated V6 CNA stated, okay R1 lets go. V9 stated she did not hear V6 call out to R1 after this. V9 stated no other words were spoken prior to the fall. V9 stated she then heard a boom and looked up to find R1 lying on the floor on side in a fetal position; R1's legs are semi contracted. R1's medical record, dated 8/17/24 at 7:08pm, V5 LPN (licensed practical nurse) noted after eating dinner, R1 was being taken to bed by V6 CNA in wheelchair upon which R1 leaned forward in wheelchair and fell forward, face down to the floor. Upon assessment R1 received moderate sized abrasion to middle of forehead with moderate blood present. R1 remains alert, and verbal during occurrence. Neurological check initiated: no deficits noted. No indication of pain or discomfort. No vomiting or loss of consciousness observed. Pupils equal and reactive to light. Level of consciousness and range of motion to all four extremities at baseline. R1's vital signs stable. EMS (emergency medical services) 911 called and arrived within 5 minutes of occurrence. R1 transported to the hospital for further evaluation. On 8/18, the emergency room nurse said R1 had CT (computerized tomography) scan of the head, cervical spine, facial bones, and all are negative. R1 received seven sutures to laceration on forehead. On 8/22 at 11:00am, V7 LPN noted V7 was notified by therapy upon R1 assessment, R1 grimacing and pointing fingers to the left knee. Upon assessment V7 noted R1's left knee swollen, light redness, warm to touch, skin intact. On pain scale, R1's pain is 6 out of 10. Acetaminophen administered. V8 NP (nurse practitioner) informed with order to send R1 back to the hospital to repeat CT scan, radiology due to R1's recent fall. On 8/22, V8 NP noted laceration of mid forehead with seven sutures, discoloration of right and left eyes, and discoloration of chin. Left knee redness and swelling, limited range of motion. 8/22 at 3:56pm, R1 returned to facility with diagnosis of non-displaced transverse fracture of left patella- brace (knee immobilizer) applied in the emergency room with order to follow up with orthopedic surgeon. This facility's investigation into R1's fall notes R1 is cognitively impaired, with memory and recall problems. R1 communicates primarily in Polish. Per V6 CNA, R1 looked tired, V6 went to R1, unlocked brakes on wheelchair and was preparing to wheel R1 to room when R1 suddenly leaned forward resulting in R1 falling from wheelchair. V6 is no longer employed at this facility and was unable to be interviewed during this survey.

Based on interview and record review, the facility failed to have effective interventions in place to keep a resident free from fall related injury for a resident with a history of falls. This failure applied to one (R6) of one resident reviewed for accidents and supervision and resulted in R6 experiencing four falls in four months and sustaining a laceration to the head requiring three staples and a subdural hematoma. Findings include: R6 is an [AGE] year-old male who has multiple diagnoses including but not limited to the following: difficulty in walking, altered mental status, need for assistance with personal care, muscle weakness, frontotemporal neurocognitive disorder, unsteadiness on feet, abnormalities of gait and mobility, failure to thrive, and dementia. Per fall report and progress notes for R6 dated 7/8/23, shows resident had an unwitnessed fall while ambulating in his room. R6 was noted to have a laceration to the back of the head and was sent to the hospital where he returned to the facility with three staples. Per fall report, no recommendations were made. Per plan of care, resident did receive a bed alarm that was later discontinued on 8/14/23 and reinstated on 9/8/23. Per fall report and progress notes for R6 dated 8/10/23, shows resident had a witnessed fall while ambulating in room. R6 was seen ambulating with shoes that were bigger than his feet. R6 fell backward in room and hit back of his head. R6's closet was assessed to ensure shoes fit, plan to ensure resident is wearing proper footwear, and roommate's shoes were moved out of reach. Per fall report and progress notes for R6 dated 9/25/23, shows resident had an unwitnessed fall and was found on the floor next to the bed. Interventions were to provide toileting assistance prior to going to bed and a medication review was completed. Per fall report and progress noted for R6 dated 10/1/23, show resident had an unwitnessed fall while ambulating in his room. R6 was found in room behind door, laying on his left side with bed sheet wrapped around lower extremity. R6 was sent to the hospital where he sustained a subdural hematoma and was later admitted to inpatient hospice. On 10/25/23 at 12:16PM, V6 (Licensed Practical Nurse) was interviewed regarding R6. V6 said I took care of R6 many times. R6 had dementia and got very confused later in the day. R6 was noncompliant with care and needed a lot of redirection. R6 would do things like put two legs in one leg pant, put items down his pants, rummage through his closet, etc. V6 said R6 was constantly getting up without asking for assistance. R6 had advanced dementia and could not use the call light. R6 needed one on one supervision but we do not provide this at the facility. V6 said, We would try and have a staff member with him at all times, but that is not something we could sustain. His (R6's) room was not close to the nursing station but was closer to the dining room. I know he had falls but I do not remember specifics. Per R6's fall reports, V6 was the nurse on 8/10/23 and 9/25/23, however V6 could not provide this surveyor with any details on the falls. It is to be noted that resident (R6) resided in a room on the other side of the unit, not visible or in close proximity to the nursing station. On 10/23/23 at 12:19PM, V17 (Restorative Director) was interviewed regarding the fall prevention program within the facility. V17 said, (V18 - Assistant Director of Nursing) and me are responsible to complete the fall reports. (V18) lets me know what interventions will be put in place and I add them to the reports and care plans. Some interventions that we utilize in the facility are low beds, floor mats, bolsters that are built in to the mattress, anti-slide wheelchair device, anti-roll back brakes, etc. On 10/25/23 at 10:45AM, V2 (Director of Nursing) was interviewed regarding R6. V2 said, I am not familiar with his (R6) falls as I started here in August. I did know (R6) was confused, impulsive, and unaware of his safety. This surveyor requested names of staff members that could provide information regarding R6 and his falls. V2 directed this surveyor to interview V18 (Assistant Director of Nursing). At 11:45AM, this surveyor attempted to interview V18 regarding R6 and his falls. However, V18 said she was not familiar with R6 and could not provide much information about his falls. On 10/24/23, all fall reports for R6 from July 2023-October 2023 were requested from both V1 (Administrator) and V2 (Director of Nursing). Fall reports for 7/8/2023, 9/25/23, and 10/1/2023 were received. The fall list reported falls for R6 on 7/8/2023, 9/25/23, and 10/1/2023. Progress notes dated 8/10/23 showed R6 sustained a fall. Requested fall report for 8/10/23 from V1 and V2 on multiple occasions on 10/25/23. This surveyor was provided a document without R6's name present and brought concern up to V1. Later, this surveyor was given a fall report from 8/10/23. It is to be noted the fall on 8/10/23 was not listed on the fall list and was not initially given to this surveyor with the requested documents. It is also to be noted that this surveyor received fall reports and care plans on 10/26/23, two days after they were requested that did not match the original documents received. It is also to be noted that some of the interventions listed on the original care plan received were not part of the new care plan received on 10/26/23. Facility policy titled Falls Prevention and Management with reviewed dated of 2/2023 states in part but not limited to the following: The purpose of this policy is to support the prevention of falls by implementation of a preventative program that promotes the safety of residents based on care processes that represent the best ways we currently know of preventing falls. Development of the fall risk care plan is based on results of the falls assessment as well as investigation of all circumstances and related resident outcomes. The care plan addresses universal fall precautions and individual fall risk factors as applies to the resident. Staff shall maintain communication with appropriate personnel when situations or residents behavior suggest that the current interventions are not effective. The facility shall re-evaluate as needed to promote safety.

Based on interview and record the facility failed to supervise a resident displaying aggressive behavior and failed to monitor the effectiveness of as needed antipsychotic medication to prevent an avoidable fall incident. This affected 1 of 3 residents (R4) reviewed for supervision and monitoring. This failure resulted in R4 having an unwitnessed fall sustaining a fracture to the right posterolateral 5th and 6th ribs. Findings Include: R4 was admitted in the facility on 4/24/23 and was assessed as High Risk for fall. Documented in Progress notes on 5/6/23 R4 had agitation behavior, hitting his (R4) face, and removed clothing in the hallway. R4's wife was with R4 and requesting to give R4 something to calm R4 down. Nurse called Nurse Practitioner and agreed to give as needed Haldol (antipsychotic), Haldol administered to R4. Documented at approx. 9:00pm, R4 has an unwitnessed fall, no fracture or injuries noted. However, R4 kept hurting himself and decision made to call emergency line (911). Documented that around 9:30 pm, R4 was taken to the hospital. Facility Reported Incident dated 5/7/23 reads in part: Date of occurrence 5/6/23, nursing supervisor (V7) notified by nurse (V8) on duty that R4 was becoming increasingly agitated, hitting himself and disrobing in the hallway. Attempts to redirect were unsuccessful. Orders received. R4 was able to be redirect to room and was observed resting in bed. Approximately 20 minutes later, R4 was noted on the floor next to his bed increased agitation, unable to be redirected. No obvious injury, no complaint of pain. R4 admitted to hospital with diagnosis of rib fracture. Final Report dated 5/13/23, reads in part: R4 was becoming increasingly agitated during the evening hours, and was observed to be hitting himself associated with self-harm and later a fall. R4 was sent out, it was not until the next day V7 was informed that R4 had fractured ribs. R4 remains in the hospital. The facility believes the injuries to be the result of R4's hitting himself. R4's hospital record reviewed. Documented that R4 has an acute mildly displaced fractures right posterolateral 5th and 6th ribs. R4 was reportedly hitting himself in the face and combative with nursing staff. R4 states he fell and landed in his back. R4 is complaining of right posterior rib pain. Presenting for agitation, tachycardic on arrival and right posterior rib tenderness. Section G (Functional Status) of the MDS (Minimum Data Set) dated 5/1/23 such as transfer, bed mobility, toilet use, locomotion in and out of unit shows R4 needs extensive assistance and one person assist. R4 has a care plan for risk for falling related to metabolic encephalopathy, vascular dementia, with other behavioral disturbances and depression. Interventions such as encourage R4 to use environmental devices such as hand grips, hand rails (start date 5/5/23), give R4 verbal reminders not to ambulate transfer without assistance (start date 5/5/23), keep bed in lowest position with brakes locked (start date 5/5/23), and provide R4 with an environment free of clutter. On 5/9/23 at 1:35pm, V7 (Nurse Supervisor) stated R4 was observed hitting himself with his hand and hitting his face. V7 stated, We redirected R4 and the wife was with him at the time. R4 was up in a wheelchair and was by the nurse's station and in the hallway while having agitation. We gave R4 psychotropic mediation to calm him down and as R4 calmed down, the wife left, he became agitated again. Approximately 10 to 15 minutes after we put R4 to bed, I was still by the nurse's station when I heard a thud sound coming in R4's room, I went to check on him and I observed R4 on the floor. Not on the floor mat, was away from it, probably a couple of steps from the foot bed side are. R4 was sitting on the floor, no injury at that time but continued to hit himself. I cannot handle R4 anymore, so I called V13 (Nurse Practitioner) and V1 (Administrator) and informed them about R4's behaviors, I was instructed to call 911. On 5/9/23 at 2:55pm, V8 (Assigned RN for R4) stated R4 was agitated and was slapping his face. R4's wife was with R4 and telling him to stop. R4 was up in his wheelchair, propelling self in the hallway with supervision of his wife. I observed R4 more than once that shift when R4 tried to get up from his wheelchair. R4 was redirected and able to sit back down in his wheelchair. V8 stated, R4 did not calm down until the psychotropic medication was given to him, but then as the wife left the facility. R4 had a fall and became restless again. R4 has a behavior of getting up from his wheelchair at times. I have observed this before this shift. R4 is redirectable. R4 can walk short distance with good balance. We just remind him and redirect him to sit back down. R4 is high risk for fall, and that is why R4's room is closer to the nurse's station so we can keep visual on R4. On 5/9/23 at 3:10pm, V10 (CNA) stated R4 was hitting himself and very agitated. Hitting himself in the face, chest area. The wife was with R4 the whole time. V10 stated, V7 assisted me to put R4 back to bed. I left V7 with R4 because there was another resident asking for assistance. I told V7 that I am going to see another resident, and V7 said 'okay'. I left V7 on the room with R4. I was providing care to this other resident when I heard a thud sound coming from R4's room. I know R4 had a bed alarm but I do not recall if I heard the alarm sounding. I went to check on R4, and I observed him sitting on the floor in his room. The floor mat was in use, but R4 was not in the floor mat. R4 was sitting on the floor in between his bed and bathroom area. R4 must have walked. R4 can walk and he walks fast. Probably 5-6 steps away from the floor mat and his bed. I observed R4 had been agitated for 4 days, getting up from wheelchair and removing his clothing, but I do not recall hitting himself before this incident. On 5/16/23 at 10:45am. V1 (Administrator) stated V1 got a call that R4 was really aggressive towards himself (R4) on 5/6/23. V1 received a call as it was happening. V7 called V1 saying that R4 was hitting himself in the chest, stomach and his face. V7 having a very hard time redirecting him. V7 reported to me that R4's wife was there at the time and asking to do something. V1 stated, I instructed V7 to call NP or MD and ask for suggestion. The next phone call I received from V7 was that the wife was leaving and at the elevator. V7 was at the nurse's station and the wife was heading towards the elevator. R4 was in his room when V7 heard a thud sound. V7 went in the room and observed R4 sitting in his bottom on the floor. V7 told me she was sending R4 out and although there is no obvious injury with V7's assessment. R4 could not tell them if R4 hit his head and so they sent R4 out just for precaution. We ended up reporting it because when they called for a report, the hospital said R4 has fractured ribs. The fractured rib, our conclusion is due to the result R4's hitting himself and being physically aggressive to himself. Per V7 there were staff that tried to redirect R4 and could not be redirected and that is why they called the physician. I cannot say if the alarm was sounding at the time of the fall. V7 said she heard thud, and I did not ask if the alarm was on at the time of R4's fall. On 5/16/23 at 11:05 am, V2 (Director of Nursing) stated R4 is behavioral, exhibiting behavior hitting himself and hard to redirect. Wife was present at the time of this behavioral incident. Sometime during the commotion was happening, R4 was given psychotropic medication to calm R4 and staff assisted R4 back into bed. Medication was effective at the time. R4's wife exited the facility and R4 again became behavioral and was found sitting on floor away from his bed and hitting himself again. R4 was reported hitting his face, chest and abdomen, and was also observed hitting himself with a drawer that he pulled from his room. R4 did not complaint of any pain after the fall incident. R4 was sent out because R4 was harm to himself at that time. Staff heard a noise in R4's room, alarm was sounding and heard a thud in the room. On 5/16/23 at 12pm, V11 (Director of Physical Therapy) stated R4 was under therapy services during his stay in the facility. R4 was walking with physical therapist with good distance of 80 to 150 feet with the rolling walker. R4 needs walker, from minimal assist to contact guard assist. Transfer contact guard assist because R4 has the tendency to do it in a hurried manner. R4 need cues and reminder and breaking down, and sequencing directions. On 5/16/23 at 1pm, V13 (Nurse Practitioner) stated V13 received a call from a nurse and reported that R4 was agitated, screaming and not redirectable and that the wife is with R4 trying to also redirect R4. R4's wife requested for medication to give R4 to calm R4 down. R4 has as needed psychotropic medication already on his profile. I gave an okay to give the medication. About another 40 minutes or so I received a call from a nurse saying that medication was effective at first and decreasing the agitation behavior but a little after the wife left the building, R4 started exhibiting behavior again. I do not recall if this was after the fall or before the fall incident but I know R4 had a fall and started exhibiting the behaviors of hitting himself as reported by the nurse. I instructed to call 911 and the reason was due to escalation of behavior can cause harm to R4 and to others. Fall Prevention and Management with a review date of 2/2023, reads in part: The purpose of this policy is to support the prevention of falls by implementation of a preventive program that promotes safety of residents based on care processes that represent the best ways we currently know of preventing falls. The fall prevention and management program is designed to assist staff in providing individualized, person-centered care. The fall prevention and management program provides framework and tools to identify and communicate about residents risk for fall. Additionally, the program addresses a safe proves to follow for supporting a resident who has experienced a fall event. Fall Prevention Practices: universal fall precautions, standardized assessment of fall risk factor, care planning and interventions to address risk factors, post fall responses including analysis of procedures and outcomes. Staff shall maintain communication with appropriate personnel when situation or resident behaviors suggest that the current intervention(s) not effective. The facility shall re-evaluate as needed to promote safety. Psychotropic Medication with a review date of 1/2021, reads in part: The facility will ensure that residents who have not used psychotropic drugs are not given unless the medication is necessary to treat a specific condition that diagnosed and documented in the clinical record. The indication for any psychotropic medication will be documented in the clinical record to include and appropriate supporting diagnosis and identification of behavioral symptom(s) being treated. Ongoing documentation must include a root cause analysis of behavioral indicators of symptoms, monitoring for efficacy and adverse consequences. Identified the behaviors will be monitored each shift along individualized interventions as well as supporting documents in the clinical record.

Based on interview and record review the facility failed to develop effective interventions to prevent or reduce the risk of falling for a resident with dementia, unsteady gait, poor safety awareness, and high risk for falls. This failure affected 1 of 3 residents (R2) reviewed for fall prevention. These failures resulted in R2 being involved in a fall incident casing pain to the left hip area. R2 was sent to the local hospital and evaluated and treated for a left hip fracture. Findings include: R2 face sheet shows R2 is [AGE] year-old female with diagnosis of dementia, anxiety disorder, psychosis, chronic kidney disease, hyperlipidemia, dysphagia, unsteadiness on feet, abnormal weight loss, altered mental status, history of acute respiratory disease, hypertension. On 2/6/23 at 12:50PM V18 (R2 family) said she doesn't feel like the facility put adequate fall interventions in place for R2. V18 said R2 fell in November and sustained a hematoma and bruise to her head. V18 said V19 (Nurse) informed her that R2's bed alarm was not in place on 12/19/22 when R2 fell . V18 said she had questions why the nurse didn't hear R2's alarm sounding but instead heard R2 yelling for help. V18 said she voiced this concern with the facility and she (V18) was told that R2 fiddled with the alarm and it was not on. V18 said R2 fell in the dining room on 12/27 and she wonder how it happened. V18 said she has concerns about R2's falls at the facility. V18 said R2 sustained a hip fracture and had surgery and R2 has since passed away. V19 was called on 2/6/23, message text and voice mail left for V19. However, V19 did not return call to surveyor during this survey. R2 MDS dated [DATE] section C denotes 1 for short term memory problems, 1 for long term memory problems, cognitive skill for daily decisions making 3 for severely impaired. Inattention (difficulty focusing attention) is noted at 2 (behavior present, fluctuates). Disorganized thinking (rambling or irrelevant conversation, unclear or illogical ideas or unpredictable switching from subject to subject) 2 is noted 2 (behavior present, fluctuates). Section G for activities of daily living denotes R2 requires extensive assist and 1-person physical assist with bed mobility. Transfer shows R2 requires extensive assist and 1-person physical assist with transfers. R2 fall report dated 11/18/22 denotes in part, R2 observed on the floor post fall. R2 unable to verbalize what happened that led to fall d/t diagnosis of dementia. R2 is in temporary new environment d/t COVID-19 status and unable to acclimate easily to environment d/t dementia. R2 transferred to hospital for further medical evaluation. CT negative for major injury. R2 to continue skilled therapies, bed alarm provided at this time. On 2/5/23 at 11:20am V5 (Restorative nurse/ falls nurse) said R2's fall was due to R2 being in a new surrounding due to room being temporary changed. V5 said the intervention was to put a bed alarm in place. R2 fall report dated 12/19/22 denotes in-part fall, time 1:50am, resident room, sleeping or lying in bed, witness-none. R2 observed on the floor post fall. R2 observed sitting on the floor, arms on each side, legs positioned straight. R2 unable to verbalize what happened that led to fall. R2 is noted sitting on folding chair brought by family, chair observed folded. Chair removed from room. Family educated in regards extra furniture in. Family verbalized understanding. Fall precautions remain in place and working condition. Staff to continue to monitor and redirect R2 as needed. On 2/5/23 at 11:20 am V5 (restorative nurse/ falls nurse) said the intervention was to remove the clutter from R2 room (regarding 12/19/22 fall). V5 said she don't know what R2 was trying to do. V5 doesn't know why R2 was out of the bed at 1:50 am (on 12/19/22). R2 fall risk dated 12/19/22 denotes in-part R2 is high fall risk (score 15), has intermittent confusion, balance problems with walking, requires use of assistive devices, R2 is up adlib, assistance to/from toilet, use antihypertensive, R2 had 1-2 falls in last 3 months, decline in functional status, referrals to fall program, continue current care plan. R2 fall investigation dated 12/27/22 denotes in-part, fall, dining room, ambulating, witness-none. Injuries- right eyebrow. R (right) forehead noted with raised discoloration area. R2 observed on the floor in dining room post fall. Per R2, she wanted to get some water. Head to toe assessment done, no injuries sustained. R2 transferred to her room, fluids offered. R2 referred to NP post fall, referred to neurologist MD (Medical Doctor) D/T (due/to) increased falls. Fall precautions remain in place and in working conditions. Staff to continue to monitor and redirect R2 as needed. Recommendations- none noted. On 2/5/23 at 11:20am V5 (restorative nurse/ falls nurse) said the intervention was to refer R2 to the neurologist (regarding 12/27/22 fall). V5 said R2 had not seen the neurologist by date of discharge on 1/5/23. V5 said the water cooler was about 10 feet from R2 wheelchair. V5 was asked if the dining room floor was wet when R2 slipped and fell . V5 said she didn't know; she would have to ask the nurse that was on duty. V5 said she completed the investigation for this fall. V5 said she did not ask the nurse if the floor was wet when R2 fell . V5 said staff was in the dining room passing dinner trays. V5 was asked why staff in the dining room didn't redirect R2 immediately when R2 got up from the wheelchair. V5 respond that, We do our best to monitor. V5 was asked if there were new interventions put in place after the fall on 12/27/22. V5 said the neuro consult. Review of R2 most current POS (physician order sheet) there are no orders noted for a neurologist consult noted. R2 progress note dated 12/31/22 while passing medications in the dining room, writer heard sound of bed alarm coming from resident's room (R2's room), immediately went to resident's room accompanied by another RN. Walked into the resident's room, observed resident lying on the floor next to her bed on left lateral side. Un-witnessed fall, resident was immediately immobilized on the floor in order to perform head to toe assessment. Assessed resident for pain, patient denied any pain. Resident A/O x 1 on and off, confused in her base line mental status. DX: Unspecified dementia with behavioral disturbance. V/S checked BP: 151/73 P:98/MIN SPO2: 97% RA T: 98.2 F tympanic R:19/min. Writer asked the resident what happened, resident unable remember and verbalize due to dementia cognitive. Resident was asked if she hit her head, resident verbalized No, I did not hit my head, only my left elbow. Resident denied any pain. Resident did not complain of any headache, nausea, or dizziness. Writer immediately performed head to toe assessment with another nurse, head, and neck intact, no redness, no discolorations or swelling observed. Writer observed small superficial skin tear on left elbow, no swelling, and no redness no S/S of infection at the area, first aid provided tolerated well. Resident is able to move her head and neck without any limitations or pain. Eyes checked: PERRLA. Resident is able to move her upper and lower extremities without any limitations, no Rotation/Deformity/Shortening noted. Hand Grasp: Equal in upper extremities. Neurological assessment initiated due to un-witnessed fall/ in resident's baseline. After the assessment resident was placed safely on her bed. Bed at lowest position, call light within reach, bed alarm on all the time. Nursing supervisor/ POA/MD made aware. R2 fall investigation dated 12/31/22 denotes fall, activity- sitting, witness- none. Injuries none noted. Immediate action neuro checks initiated, placed in wheelchair, 1:1 supervision implemented, ROM (range of motion) W/I (within) normal limits for residents, POA notified of occurrence, resident care card updated, assess for pain, encourage resident to ask for assistance before standing, referred to PT, placed in bed, head to toe body check, notified immediate supervisor, CNA assigned updated, refer to other physician, neuro assessment, MD notified, refer to OT. Conclusion written by V5 (restorative nurse) entered on 2/4/23 at 12:34 pm R2 observed on the floor next to her bed post fall. R2 unable to verbalize to staff what happened that led to fall D/T Dx (diagnosis) of dementia. R2 denied pain or discomfort post fall. First aide provided to left elbow by NOD (nurse on duty). Staff to continue to remind R2 not ambulate/ transfer without staff assistance. R2 referred to skill therapies post fall. R2 has fall preventions measures in place and in working condition. Staff to continue to monitor and redirect. On 2/4/23 at 4:10 p.m. V7 said on 12/31/22 she was near the dining room when she heard a bed alarm and as she went to see where the alarm as coming from, she noticed R2 laying on the floor near her bed. V7 said R2 had an abrasion to the left elbow and first aid was rendered. V7 said she completed an assessment along with the other nurse. R2's range of motion to the upper and lower extremity was within normal range for R2. V7 said R2 denied pain and could not say what happen. V7 said she had just walked past R2 room and saw R2 sitting on her bed. V7 said her, another nurse and V6 all got R2 up and placed R2 in the wheelchair and escorted R2 to the dining room. V7 said R2 has dementia and has poor safety awareness. V7 omitted going into R2 room to determine if R2 needed something and or to determine why was R2 sitting at R2's bedside just prior to the fall. V7 was asked what R2's behavioral disturbance was. V7 said she did not know about R2 having a behavioral disturbance. On 2/5/23 at 11:20 am V5 (restorative nurse/ falls nurse) said the intervention was to give R2 verbal reminders not to ambulate without assistant. V5 said this is done if the staff sees R2 trying to get up from the bed. V5 was asked if the staff was doing that already. V5 responded, I care planned that on 1/2/23. V5 said R2 was referred to physical therapy also. V5 was asked what was R2 trying to do when R2 fell . V5 said R2 could not say because R2 has dementia. V5 was asked if the nurse should have gone in to R2's room see if she needed anything when she saw R2 sitting at the bed side. V5 responded, Yeah if she saw (R2) trying to get up, but she didn't know if R2 was trying to get up. V5 was asked if it's reasonable to believe that one must come to a sitting positing before getting up from bed, and that could be an indicator that a person may be trying to get up if they're sitting on the bed. V5 said R2 would usually sit in her chair at the bedside, so she would not think R2 was trying to get up from bed. V5 said she doesn't know what R2 was trying to do. V5 said R2 has dementia and poor safety awareness. V5 said R2's room is in a high traffic area so R2 can be monitored by staff as they walk pass or are sitting at the nurse station. V5 was asked how was R2 being monitored. V5 said staff should check on R2 frequently, redirect R2 if R2 is trying to get out of bed, toilet R2 as needed, provide water if R2 needed it. V5 said R2 was put on 1:1 monitoring after the fall on 12/31/22. V5 said she conducts the fall investigation at the facility and the root cause of the fall and interventions are developed with the interdisciplinary team. V5 said the facility does not have a fall prevention program. They use universal fall precautions. V5 said the fall interventions should be developed and implemented based on the root cause of the fall. V7 (Nurse) omitted putting R2 on 1 to 1 monitoring after the fall on 12/31/22. V7 said R2 was put in the wheelchair and taken to the dining room with the other residents. On 2/6/23 at 2:13pm V9 (ADON) said all falls should be thoroughly investigated. V9 said the falls are reviewed in the daily morning meetings. V9 said the falls interventions are developed with the interdisciplinary team. V9 said, we don't know what R2 was trying to before she was observed on the floor on 12/31/23. V9 said it is not uncommon for R2 to be sitting at the bedside because that's what R2 used to do before she started having falls. V9 said R2 had COVID-19 infection and was weaker. V9 was asked if R2 was weaker according to what she just said, would it be reasonable to believe R2 could fall if she is observed sitting at the bedside alone, has poor safety awareness, needs one-person physical assist with bed mobility, and recently had a fall from the bed and is a high fall risk. V9 said she would expect the nurse to go in R2 room if she saw R2 at sitting at the bedside to redirect R2. V9 said R2 needs one-person assist with bed mobility and transfer. Review of R2's current POS shows there were no orders noted to limit R2's movement or keep R2 in the bed until R2 gets the left hip X-ray completed. V10 (CNA) said R2 was up in the wheel chair for her shift (3-11pm) on 1/4/23. R2 Xray dated 1/4/23 shows in-part R2 had the alignment is normal, acute left femoral neck fracture. The joint appears well maintained. The soft tissue is unremarkable. R2 progress note dated 1/5/23 denotes in-part on call Doctor called and ordered the patient to be sent to ER (emergency room ) for evaluation. On 2/5/23 at 11:20am V5 said that fall risk assessment is not accurate because R2 should not be up at liberty, R2 requires monitoring. V5 said the fall risk assessment should be completed accurately because that information is used to developed plan of care for fall intervention. R2 fall risk assessment dated [DATE] denotes a fall score of 22 (high risk). R2's care plan shows problem start date 2/3/2020. R2 is at risk for falling R/T poor safety awareness, d/t Dementia Dx (diagnosis), Anxiety, and Unsteadiness on feet. R2 is non-compliant with fall prevention measures. R2 will remain free from injury r/t (related to) fall target date 2/28/23. Xray of Left hip/femur/ thigh ordered d/t complaints of pain post fall. R2 referred to skilled therapies post fall. Give R2 verbal reminders not to ambulate/transfer without assistance. Neuro consult d/t recent falls. R2 referred to NP post fall. Provide R2 an environment free of clutter. Provide R2 with safety device/appliance: bed alarm. Transfer R2 to RMC ER for further medical evaluation post fall. Assure R2 wears proper well-maintained footwear. Assure floor is free of glare, liquids, foreign objects, encourage R2 to assume a standing position slowly, encourage R2 to use environmental devices such as hand grips, handrails, keep call light in reach at all times, observe frequently and place in a high traffic area when out of bed, occupy R2 with meaningful distractions, provide R2 with an environment free of clutter, keep personal items and frequently used items within reach. Facility Fall Prevention and Management policy with revised date on 3/2022, denotes in part the purpose of this policy is to support the prevention of falls by implementation of preventive program that promotes the safety of resident based on care process that represents the best ways we currently know of preventing falls. The falls prevention and management program is designed to assist staff in providing individualize, person centered care. The falls prevention and management program provide a framework and tools to identify and communicate about a resident risk of falls. Additionally, the program addresses a safe process to follow for supporting a resident who has experienced a fall event. Fall prevention and management practices includes separate activities. Universal fall precautions, standardized assessment of fall risk factors, care planning and interventions to address risk factors, post fall response including analysis of procedures and outcomes. Universal fall precautions are safety measures that are taken to reduce the chance of falls for all residents, regardless, of individual fall risk. The fall risk assessment is used to identify fall risk factors. Developing of fall risk care plan is based on results of the fall assessment as well as investigation of all circumstances and related resident outcomes. The care plan addresses universal fall precautions and individualize fall risk factors as applies to the resident. A fall care plan will be implemented as part of the baseline care plan to address universal fall precautions and as part of the comprehensive care plan utilizing information from the fall risk assessment. The care plan will be reviewed and revised at least quarterly and with any fall event the resident might experience. Alarms may be useful method of altering staff of a resident's movement which may pose a risk to their safety. Staff shall maintain communication with appropriate personnel when situations or resident behaviors suggest that the current interventions are not effective. The facility shall re-evaluate as needed to promote safety. Past history of a fall is the single best predictor of future falls. In fact, 30-40% of those residents who fall will do so again. This, it is critical for staff to respond quickly and effectively after a fall. A post fall response includes immediate actions to assure the safety of the resident, assessment/ clinical review, investigation and observation of the fall circumstance, implementation of immediate actions to prevent further falls, notification of appropriate parties.

Based on observation, interview, and record review, the facility failed to provide a resident who is fully dependent on staff and at risk for developing pressure ulcers, with the necessary care and services to prevent the development of multiple pressure ulcers by not providing timely assessment of noted skin alteration. The facility also failed to follow their pressure ulcer treatment and management plan by not taking the resident's individualized needs/risk factors into account to include nutritional support and mobility (including repositioning and range of motion) when developing the resident's plan of care. This failure applied to one (R111) of six residents reviewed for neglect and resulted in R111 developing three facility acquired pressure ulcers; an unstageable wound to the left buttock, a stage IV wound on the left hip, and a stage IV to the sacrum. Findings include: R111 is a [AGE] year old female who was originally admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (Minimum Data Set) Annual assessment dated [DATE] notes that R111 has one facility acquired stage IV pressure ulcer and is totally dependent on staff for care, requiring 2+ staff assist for transfers and bed mobility. Per facility wound assessment since 10/11/22, resident has multiple facility acquired pressure ulcers including an unstageable to left buttock (2.0 cm x 1.5 cm) originally identified 10/11/22, stage IV to left hip (4.7 cm x 2.0 cm) originally identified 10/3/22, and a stage IV to sacrum (4.8 cm x 3.6 cm) originally identified 08/08/22. On 10/11/22 at 1:00 PM, V20 (Wound Care Registered Nurse) was observed performing wound care. V20 said R111's left hip and sacrum pressure ulcer are both facility acquired. V20 stated she was also notified today of a new skin alteration. During treatment, V20 said the new skin alteration is a new facility acquired unstageable pressure ulcer (2.0 cm x 1.5 cm). Says the wound doctor does come once a week, typically on Mondays, to provide treatment. Per Wound Management Detail Report dated 09/22/22 and created by V15 (RN/ADON) states in part but not limited to the following: Left hip skin tear (4.0 cm x 4.0 cm) was originally identified on 09/22/22: Skin Tear Type: Total flap loss: entire wound bed exposed; Comments: Resident noted with new skin alteration to left hip. Per medical record documentation, wound care doctor did not see and assess this skin alteration until 10/3/22 (11 days later). Documentation from wound doctor on 10/03/2022 classified skin alteration as a stage IV pressure ulcer. There was no modification to the resident's plan of care to address this change in skin alteration. Last noted care plan interventions related to skin alteration were documented on 8/8/2022. Per Wound Management Detail Report dated 10/03/2022, created by V20 (RN) states (in part): Stage IV left hip pressure ulcer (5.0 cm x 2.0 cm) originally identified on 10/03/2022: Tissue Type: Necrotic Tissue, Wound edges/margins: well defined wound edges, Wound healing status: Declining, Comments: Seen by wound MD, wound reclassified. Wound bed 80% necrotic tissue, 20% skin. Wound noted declining, resident has poor appetite, and resident is bedbound. Review of medical record does not indicate that any additional assessment or care plan interventions were put in place to specifically address declining wound, resident's nutritional status, and lack of mobility. R111's current care plan with problem start date of 08/11/2016 includes: Problem: R111 is at risk to develop further pressure ulcers and/or skin breakdown due to diabetes mellitus, [CONDITION(S)], dysphagia, hypertension, muscle weakness, difficulty walking, repeated falls, [CONDITION(S)] and collapse, anxiety, incontinence, decreased mobility, and decreased body activity. Also requires total assistance to do activities of daily living. Goal: R111's wound sites will show signs of improvement through the next review date. Interventions include: Approach: Daily Skin Checks During this survey, no documentation provided to show that resident was getting daily skin checks as ordered. On 10/12/22 at 2:00 PM, V15 (RN/ADON) was interviewed regarding resident's active pressure ulcers. V15 said, the sacrum, left hip, and left buttock pressure ulcers are all facility acquired .originally identified the left hip wound as a skin tear due to it being superficial. R111 did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked V15, if in her experience, she has seen a wound deteriorate from a skin tear to a stage IV pressure ulcer in less than a week and she did not provide an answer. V15 said, it was noted that (R111) started declining in May of 2021. During this survey, no documentation of modification to resident's plan of care to show that resident was declining or that interventions were put in place to address R111's decline. Facility policy titled 'Pressure Ulcer Prevention Protocol' dated 05/18 states in part but not limited to the following: Objective: Residents will be assessed to determine the risk factors for pressure ulcer development. Procedure: 4. Interventions necessary to maintain skin integrity or to promote healing will be incorporated into the plan of care based on each resident's individual needs and risks. Facility policy titled 'Pressure Ulcer Treatment and Management' dated 05/17 states in part but not limited to the following: Objective: Residents who receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Guidelines: 8. Residents with pressure ulcers will be determined to be at high risk for pressure ulcer prevention and all components of the At Risk protocol will include: pressure relieving devices, nutritional support, and assistance with mobility including repositioning and ROM as outlined in the At Risk Protocol.

Based on observation, interview, and record review, the facility failed to perform an initial pain screening and comprehensive pain assessment upon readmission for a resident (R57) who is at risk for pain; failed to ensure an ongoing pain management program was implemented for a resident (R57) who required treatment and care that was not reflected in resident's individualized comprehensive care plan; failed to follow their facility policy and procedure for pain management. This failure has caused R57's pain level to remain consistently high without successful interventions by the facility. Findings include: On 10/09/2022 at 10:53 AM, surveyor heard yelling out while making observations on the third floor. At 10:55 AM, entered R57's room and observed resident lying in bed, sling loosely in place to left upper arm, and visibly experiencing pain. While weeping and holding her left upper arm, R57 said that she broke her arm and it hurts so much. R57 said, taking pain medicine but it is not enough. R57 said she last had pain medicine this morning and has asked for more, then said, the nurse, he knows. R57 then informed surveyor that she wants an increase in her pain medicine. When asked to rate her current pain level on a numerical scale of 0-10, R57 rated her current pain level at 20 then said it makes her feel bad and wants to die when having so much pain. On 10/09/2022 at 12:25 PM, reviewed R57's electronic medical record with the following noted: Past medical history not limited to Nondisplaced Fracture of Upper End of Left Humerus, Hypertensive Heart and Kidney Disease with Heart Failure and Stage 1-4 Chronic Kidney Disease, Unspecified Abnormalities of Gait and Mobility, and Pain in Left Shoulder. Active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Readmission pain screening and comprehensive pain assessment dated [DATE] documents that R57 is unable to move 1 or more extremities, pain screening section 1 documents that in the last 5 days, R57 had vocal complaints of pain, had received scheduled and as needed pain medication. Pain assessment section indicates to complete for residents identified as experiencing pain in section 1. Section 2 and remainder of pain assessment which included diagnosis, frequency of pain, effect on sleep and activities, pain site, verbal descriptor pain scale, accompanying symptoms, character/duration/onset of pain, interventions and outcome was not completed for R57. On 10/10/2022, reviewed R57's electronic medical record with the following noted: Nurse Practitioner note dated 10/09/2022 12:48PM showed, Patient seen and examined at bedside. Care discussed with staff RN. Reason for the visit: LT shoulder/arm pain. HPI: Patient is a [AGE] year-old female seen today for complaints of LT shoulder/arm. c/o pain in LT shoulder/arm. resting in bed, appears agitated. on [MEDICATION(S)] 5/325 for pain control. Patient c/o severe pain despite [MEDICATION(S)] therapy. give one-time [MEDICATION(S)] 5/325 for breakthrough pain. increase [MEDICATION(S)] to 10/325 Q6hPRN. Nurse's note dated 10/09/2022 12:51 PM showed, late entry: resident continuous screamed for her PRN [MEDICATION(S)] 5-325 mg to be increased after ad med, stating it has not been strong enough to subside her pain. NP made aware and gave N.O to give resident another 1 tab of the [MEDICATION(S)] 5-325 mg and increased the strength of the [MEDICATION(S)] from 5-325 mg to 10-325 mg. Nurse's note dated 10/10/2022 07:23 AM reads, Patient was awake on and off, Received [MEDICATION(S)] from pharmacy at 0300 and a dose was given immediately. Nurse's note dated 10/10/2022 12:36 PM reads, [MEDICATION(S)] given for pain PRN as requested. R57's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R57's Care plan includes, (last reviewed 09/12/2022) at risk for alteration in psychosocial wellbeing; problem start date of 06/11/2021. Care plan also showed, R57 has alteration in Rest and Comfort r/t pain secondary to Polyneuropathy, [CONDITION(S)] of unspecified finger and diabetic amyotrophy, left humerus fracture. Edited: 10/10/2022. On 10/11/2022 at 1:26 PM, surveyor observed R57 lying in bed resting. She rated her current pain level on numerical scale of 0-10 at 3 then added when I move the pain is 10. On 10/12/2022, reviewed R57's electronic medical record with the following noted: Medication Administration History from 10/01/2022-10/11/2022 showed R57 received acetaminophen 650mg on 10/8 at 10:17am for pain to left shoulder rated at 6 and at 4:48pm for pain rated at 8. On 10/10/22, R57 received acetaminophen 650mg at 12:09am for pain rated 6. On 10/10/22, R57 received [MEDICATION(S)]-acetaminophen 10-325mg at 3:27am for pain rated at 8 and at 12:22pm for pain rated at 5. On 10/11/22, R57 received [MEDICATION(S)]-acetaminophen 10-325mg at 1:52am for pain rated at 7 and at 8:27am for pain rated at 7. It was noted that R57 did not receive her [MEDICATION(S)] pain patch to her left shoulder on 10/5, 10/7, 10/10, and 10/11 because patch was unavailable. Medication Administration History from 10/04/2022-10/09/2022 showed the following: 10/7/22 at 5:52AM, R57 received [MEDICATION(S)]-acetaminophen 5-325mg for pain to left shoulder rated at 9. 10/07/22, R57 received [MEDICATION(S)]-acetaminophen 5-325mg for pain rated at 7 at 12:00pm and again at 8:05pm for pain rated an 8. 10/08/22 at 5:58AM, R57 received [MEDICATION(S)]-acetaminophen 5-325mg for pain rated at 7 - at 12:17pm for pain rated at 6 - and again at 10:50pm for pain rated at 8. R57's pain assessment on 10/4/22 documents that R57 rated her pain level at 8 on 2 of 3 shifts. 10/6 she rated her pain level at 7 during PM shift. On 10/7 she rated her pain level at 6 during PM shift. On 10/8, R57 rated her pain level at 6 on day shift and 8 on PM shift. On 10/10, she rated her pain level at 5 on day shift and 8 on PM shift. On 10/11, R57 rated her pain level at 7 on day shift. Nurse's note dated 10/11/2022 06:17 AM showed pain med @ 0153 given slightly relieved. On 10/12/2022 at 1:15pm, interviewed V3 (Director of Nursing) who said residents are assessed for pain upon admission then quarterly if identified. She then said when admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 added that the nurse who completed R57's readmission assessment had missed multiple sections within the pain screening and assessment portion. Reviewed facility's Pain Management policy last reviewed/revised 05/17 that showed the following: Objective: It is the policy of this facility to screen all residents for pain; identify those who are experiencing pain; and assess and develop an effective individualized pain management care plan. Procedure: 1. All residents will be screened for the presence of pain symptoms. The facility nursing staff will complete the pain screening form upon admission, with quarterly assessments, readmission from hospital stay. 3. The resident without cognitive impairment will be assessed utilizing the numeric rating scale and verbal descriptor scale. 4. The physician will be informed of resident's initial complaint of pain and review the resident's pain management plan during routine visits. 5. An individualized pain management care plan will be developed for each resident who experiences pain.

Based on observation, interview, and record review, the facility failed to prevent a resident who is fully dependent on staff for care from developing facility acquired pressure ulcers. This failure applied to one (R111) of six residents reviewed for pressure ulcers and resulted in R111 developing three facility acquired pressure ulcers; an unstageable wound to the left buttock, a stage IV wound on the left hip, and a stage IV to the sacrum. Findings include: R111 is a [AGE] year old female who was originally admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (Minimum Data Set) Annual assessment dated [DATE] notes that R111 has one facility acquired stage IV pressure ulcer and is totally dependent on staff for care, requiring 2+ staff assist for transfers and bed mobility. Per facility wound assessment since 10/11/22, resident has multiple facility acquired pressure ulcers including an unstageable to left buttock (2.0 cm x 1.5 cm) originally identified 10/11/22, stage IV to left hip (4.7 cm x 2.0 cm) originally identified 10/3/22, and a stage IV to sacrum (4.8 cm x 3.6 cm) originally identified 08/08/22. On 10/11/22 at 1:00 PM, V20 (Wound Care Registered Nurse) was observed performing wound care. V20 said R111's left hip and sacrum pressure ulcer are both facility acquired. She was also notified today of a new skin alteration. During treatment, V20 said the new skin alteration is a new facility acquired unstageable pressure ulcer (2.0 cm x 1.5 cm). Says the wound doctor does come once a week, typically on Mondays, to provide treatment. Per Wound Management Detail Report dated 09/22/22 and created by V15 (RN/ADON) states in part but not limited to the following: Left hip skin tear (4.0 cm x 4.0 cm) was originally identified on 09/22/22: Skin Tear Type: Total flap loss: entire wound bed exposed; Comments: Resident noted with new skin alteration to left hip. Per medical record documentation, wound care doctor did not see and assess this skin alteration until 10/3/22 (11 days later). Documentation from wound doctor on 10/03/2022 classified skin alteration as a stage IV pressure ulcer. There was no modification to the resident's plan of care to address this change in skin alteration. Last noted care plan interventions related to skin alteration were documented on 8/8/2022. Per Wound Management Detail Report dated 10/03/2022, created by V20 (RN) states (in part): Stage IV left hip pressure ulcer (5.0 cm x 2.0 cm) originally identified on 10/03/2022: Tissue Type: Necrotic Tissue, Wound edges/margins: well defined wound edges, Wound healing status: Declining, Comments: Seen by wound MD, wound reclassified. Wound bed 80% necrotic tissue, 20% skin. Wound noted declining, resident has poor appetite, and resident is bedbound. Review of medical record does not indicate that any additional assessment or care plan interventions were put in place to specifically address declining wound, resident's nutritional status, and lack of mobility. R111's current care plan with problem start date of 08/11/2016 includes: Problem: R111 is at risk to develop further pressure ulcers and/or skin breakdown due to diabetes mellitus, [CONDITION(S)], dysphagia, hypertension, muscle weakness, difficulty walking, repeated falls, [CONDITION(S)] and collapse, anxiety, incontinence, decreased mobility, and decreased body activity. Also requires total assistance to do activities of daily living. Goal: R111's wound sites will show signs of improvement through the next review date. Interventions include: Approach: Daily Skin Checks During the course of this survey, no documentation provided to show that resident was getting daily skin checks as ordered. On 10/12/22 at 2:00 PM, V15 (RN/ADON) was interviewed in regard to resident's active pressure ulcers. V15 said, the sacrum, left hip, and left buttock pressure ulcers are all facility acquired .originally identified the left hip wound as a skin tear due to it being superficial. R111 did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Asked V15, if in her experience, she has seen a wound deteriorate from a skin tear to a stage IV pressure ulcer in less than a week and she did not provide an answer. V15 said, it was noted that (R111) started declining in May of 2021. During the course of this survey, no documentation of modification to resident's plan of care to show that resident was declining or that interventions were put in place to address R111's decline. Facility policy titled 'Pressure Ulcer Prevention Protocol' dated 05/18 states in part but not limited to the following: Objective: Residents will be assessed to determine the risk factors for pressure ulcer development. Procedure: 4. Interventions necessary to maintain skin integrity or to promote healing will be incorporated into the plan of care based on each resident's individual needs and risks. Facility policy titled 'Pressure Ulcer Treatment and Management' dated 05/17 states in part but not limited to the following: Objective: Residents who receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Guidelines: 8. Residents with pressure ulcers will be determined to be at high risk for pressure ulcer prevention and all components of the At Risk protocol will include: pressure relieving devices, nutritional support, and assistance with mobility including repositioning and ROM as outlined in the At Risk Protocol.

Based on Observation, Interview and Record Review the facility failed to correctly assess Pressure Sore of 1 (R58) out of 3 residents reviewed for pressure sores in the sample of [AGE]. This failure led to R58 having open and bleeding pressure sore on the sacral area. Findings include: On 02/11/20 12:22 PM. R58 cannot express his need and was not able to verbalize when questions were asked. R58 has enteral feeding connected and was running continuously. R58's spouse stated that R58 has wound on the tail bone or sacral area and presented a [MEDICATION NAME] dressing taken out of the drawer. Also stated that this problem is continuing for a long time. On 0[DATE] 10:02 AM. R58 during bedside care with V9 and V10 both Certified Nursing Assistants was noted to have a pressure wound with slough and bleeding in the sacral area and scab on the right buttock. The area was also noted to be raw with redness. Both V9 and V10 were unable to determine with certainty why the sacral area was bleeding. R58 was also noted to be on aLow Air Loss Mattress with bed sheets and draw sheets placed underneath R58. On 0[DATE] 10:55 AM. R58 was then seen by V11 and V12 (Licensed Practical Nurses that are the Wound Coordinators). V12 stated the following: I agree, the sacral area is open and bleeding, but said it was a scab instead of a slough. V12 stated that she will change the dressing to include protected barrier and protected dressing and told the nurse at the Nurse's Station to get hold of the doctor to get an order. V12 stated that resident wound on the sacral area was not seen by the Wound Doctor for approximately 8 months. On [DATE] 9:15 AM. V11, V12 and V2 (Director of Nursing-DON) during interview stated that facility assessed the sacral area as excoriation not pressure. But agreed that sacral area has a Stage 4 pressure sore in the past. V12 now stated that she was not sure if there was a scab on the sacral area. V11 also stated that when she saw R58, she just looked at the area and placed barrier cream. On [DATE] 10:45 AM. V11, (DON), stated after R58's sacral wound was seen again with the yellowish slough: when a sacral pressure sore staged as 4 closed and reopened again it should be staged as 4. Minimum Data Set (MDS) most recent comprehensive assessment dated [DATE] Section C reads that R58 Brief Interview for Mental Status was not done because R58 is rarely or never understood. Section M reads that R58 has unhealed Pressure Ulcers / Injuries and has a Pressure Ulcer / Injury, over bony prominence. R58's Progress Notes dated [DATE] at 8:56 AM reads: R58 skin was intact, no excoriation or scab was mentioned. Skin - Weekly Treatment (Non-Pressure Ulcer) Documentation dated [DATE]20 reads: Bilateral Buttocks - Excoriation. Skin - Weekly Treatment (Non-Pressure Ulcer) Documentation dated 2/11/2020 reads: Bilateral Buttocks - Excoriation. Both assessments no Sacral area assessment. Both assessments did not mention that Sacral area has neither pressure sore, excoriation or it was assessed at all. It also does not mention that there was a wound with a scab on the right buttock. Wound Evaluation and Management Summary dated 12/24/18 reads that R58 has Stage 4 Pressure Sore on the Sacral Area. According to the National Pressure Ulcer Advisory Panel, if a pressure ulcer reopens in the same site, the ulcer should be listed at the previous staging diagnosis (for example, if it was a Stage IV before it closed, it would be a Stage IV when it reopened). Remember that pressure ulcers heal to a progressively more shallow depth. They don't replace lost muscle, subcutaneous fat, or dermis before they re-[MEDICATION NAME]. Instead, the full-thickness ulcer is filled with scar tissue composed primarily of endothelial cells, fibroblasts, collagen, and extracellular matrix. A Stage IV pressure ulcer, therefore, can't become a Stage III, Stage II, or subsequently Stage I pressure ulcer. Braden assessment dated [DATE] reads that R58's score was 12 indicating High Risk for Pressure Ulcer. Dietary recommendation dated 1/14/20 reads: Concern Re-admit, increase nutritional needs, skin remains impaired. 1. Discontinue 240 cc flush every q shift 2. 2[AGE] cc flush every q shift (825 cc per day) 3. [MED] SF AWC 30 cc BID (Protein for aid in the healing of the wound) 4. Weekly weights 4X per week Care Plan reads: Measure and record wound sites weekly. Dated 1/31/20. Daily skin check. Dated 1/17/20. Refer and report skin problems and signs of skin breakdown (red, sore and broken skin). Dated 1/17/20. Wound MD consultation. Dated 1/3/20.

Based on interview and record review the facility failed to develop plan of care with intervention utilizing 2-person physical assist for a resident totally dependent on staff for activities of daily living to reduce or prevent a fall incident while staff is providing a shower for 1 of 3 residents (R1) reviewed for supervision during showers. This failure resulted in R1 falling out of the shower chair while in the shower room. R1 was observed grimacing of pain, an x-ray was obtained that documented R1 had sustained a right inter trochanter fracture, R1 was sent to the local hospital for evaluation and treatment of [REDACTED]. Findings include: On 7/9/19 at 1:35PM Observed (R1) on bed, slide down to the foot part of the bed. Bolster bed attached to the left side on the bed, while the other bolster on the right side of the bed was on the floor, (R1) has left heel protector, while the other is on the recliner chair. (V3 CNA (Certified Nurse Assistant) Supervisor) stated that she is waiting for another CNA to pull up (R1). (V4 CNA) came to help (V3). (V3) and (V4) pulled up (R1), provided incontinence care, repositioned and applied bilateral heel protector. Observed right hips dressing with purplish bruise on right upper hip extending to right buttocks. (V3) stated that (R1) has bilateral bolsters for his fidgeting. (R1) was just transferred back to bed from high back recliner chair. (R1) is on low bed with floor mat on the left side of the bed. (R1)'s right side of the bed was pushed against the wall. (V4) stated that she heard from the report that (R1) fell but did not know the details. (R1) is actively constantly moving and on fall precaution. (R1) needs total care with ADLs (Activity of daily living) and transfers. (R1) uses Hoyer lift for transfers. On 7/9/19 at 2:33PM (V6 Restorative Director/Fall coordinator) stated that fall assessment is done upon admission, quarterly, annual and after each fall. Fall interventions depends on individual needs. Record review of (R1)'s comprehensive care plan last revised 7/5/19 with (V6) indicated (R1) requires bolsters to bed due to poor posture. He is cognitively impaired and is physically and mentally unable to get out of bed on his own. Bolsters are provided for positioning due to poor trunk control. He is a mechanical lift transfer due to generalize muscle weakness. He has behavioral problem manifested by sign and symptoms of agitation and anxiety- calling out, restlessness movement in chair, dangling his legs off the arm rest of his specialized chair, removing the bolsters from the bed. He is at risk for fall due to decreased bed mobility, dementia, anxiety disorder and other medical conditions. He is on [MEDICAL CONDITION] medication. He has history of right femur fracture due to fall s/p (status [REDACTED]. (V6) admitted that for safety issue, (R1) needed to have 2 persons assist during shower. Shower supervision instruction was not addressed in care plan of (R1). (V6) admitted that she did not address precautions of 2 persons assist in giving shower in care plan but verbally informed the staff. Review of fall precaution care plan was updated but not individualized to the need of (R1) based on the root cause analysis of fall incident. (V6) stated that after the fall incident there should be 2 persons assist giving shower to (R1) to prevent fall. Record review of (R1)'s most recent fall assessment prior to fall incident dated 4/4/19 documented by (V6 Restorative Director/Fall Coordinator) indicated High fall risk. Record review of (R1) 's fall incident dated 6/26/19 with (V6 Restorative Director/Fall Coordinator) indicated (V9 RN (Registered Nurse)) observed shower room alarm and heard (V8 Agency CNA) called for help. (V9 RN) immediately went to shower room, observed (R1) on the shower floor lying on his back. (V9 RN) asked (V8CNA) what happened and (V8 CNA) informed (V9 RN) that (R1) was anxious and began to slide from the shower chair. (V8 CNA) lowered (R1) to the shower floor, to prevent injury. (V9 RN) performed head to toe assessment. (R1) with ROM (Range of motion) at baseline. No shortening of extremity observed, no swelling or discoloration noted. (R1) observed grimacing, due to mental cognition unable to give accurate indication of exact location of pain. (V9 RN) with 3 other CNAs assisted (R1) back to bed. Physician notified with order for 650mg Tylenol for pain and stat X-ray of bilateral hips and lower back. Vital signs 164/78, 60, 18, 97.6F, 98% O2 saturation. Supervisor and DON made aware. X-ray results indicated right inter trochanter fracture. (R1) was sent to hospital for evaluation on 6/27/19 and was admitted with [DIAGNOSES REDACTED]. Recent incident occurrences (last 60 days) indicated in report included: on 6/12/19 (R1) obtained skin tear on right elbow measures 0.1cm x 0.1cm x 0.1cm while CNA was giving shower. Record review of Facility's reportable fall incident initial report dated 6/27/19 and final report dated 7/3/19 sent to IDPH. Observed discrepancies in report that were discussed with (V1 Administrator) and (V2 DON). V1 and V2 stated the fall incident was happened in 4th floor shower room not 2nd floor. (V8 Agency CNA) was not (R1)'s usual CNA who gives him showers. Interviewed with (V8) on 7/10/19 at 3:29pm stated that it was the first-time giving shower to (R1) on 6/26/19, the day of fall incident. (V8 CNA) stated that (V9 RN) assisted V8 to transfer (R1) to shower chair in his room using Hoyer lift. (V8 CNA) wheeled (R1) to shower room. (V8 CNA) turned V8's back away from (R1) to grab the towel, (R1) become restless and slid from the shower chair. (V8 CNA) tried to ease (R1) down to the floor and called for help. (V8 CNA) stated that if there was another CNA to assist V8, the fall could be have been preventable. All CNAs were busy at that time and (V9 RN) was busy passing medications to residents. (R1) care plan was updated by (V6 Restorative Director/ Fall Coordinator) on 7/9/19 indicated (R1) requires assistance of 2+ staff members while receiving shower in shower room. On 7/10/19 at 4:22PM (V21 CNA), (V13 Agency CNA) and (V3 CNA supervisor) prepared (R1) for transfer from bed to shower chair. (V22 CNA) also came to help. There were total of 4 CNAs preparing (R1) for shower. (R1) was transferred to specialized shower chair using Mechanical lift. Observed (R1) lethargic dosing on and off. Calm and quiet. Asked (V21 CNA) if it was safe for (R1) to provide shower when he was sleepy. (V21 CNA) stated He is okay. He is awake. They wheeled (R1) to shower room. 3 CNAs (V21), (V13) and (V22) stayed in the shower room. (V21 CNA) provided shower to (R1) while the 2 CNAs handled bath supplies to (V21). (V22 CNA) in and out of the shower room to get bath supplies. Shower was completed at 4:45PM. During complaint investigation dated 7/9/10 to 7/11/19 at different times, interviewed with the following employees who were familiar with (R1)'s physical and mental conditions: (V3 CNA Supervisor), (V6 Restorative Director/ Fall coordinator), (V7 CNA), (V8 Agency CNA), (V9 RN), (V12 Restorative nurse/fall coordinator), (V13 Agency CNA), (V17 Nurse Practitioner), (V19 Psychiatrist), (V21 CNA) and (V22 Agency CNA). All of them stated that the (R1)'s fall incident was preventable if there was adequate supervision of 2 persons assist during shower. All of them stated that there should be a 2 person assist during shower for safety purposes. All CNAs (except for (V8)) interviewed stated that they use 2 persons assist to (R1) during shower. On 7/10/19 at 11:17AM (V17 Nurse Practitioner) stated that (R1) is on strict fall precaution due to history of dementia, stays on recliner chair due to poor trunk control, agitation, anxiety and restlessness. (V17) agreed with problems identified in (R1)'s care plan. (V17) stated that R1 should have 2 persons assist for shower for safety issues. (R1)'s fall incident is preventable with adequate supervision. (V17) added that shower room is uncontrolled environment. Water temperature and slippery floor will increase restlessness especially when a resident has dementia, their response during shower that will require increase supervision. On 7/10/19 at 11:56AM (V19 Psychiatrist) stated that (R1)'s fall was preventable. Based on (R1)'s physical and mental clinical condition, (R1) should have adequate supervision of 2 persons assist when giving shower. Record review of Facility's fall prevention in-services (before and after the fall incident) dated 3/28/19, 4/19/19, 4/30/19, 5/4/19, 5/31/19, 6/11/19 and 6/28/19. (V8 Agency CNA) who was involved with (R1) fall incident did not attend any of the in-services given by the facility. Record review of Facility's Fall Reduction Program revised date 4/2019 given by (V2 DON) indicated: Objective: Fall Reduction program promotes the safety of residents in the facility. The program intent is to assist clinical staff in determining the needs of each resident through the use of standard assessments, the identification of each resident's individual risks, and the implementation of appropriate interventions, supervision, and or assistive devices deemed appropriate. Program contents: 6. Communication with direct care staff members 7. Care Plan incorporates: preventive measures; modification and implementation of care plan approaches based on newly identified risk or recent fall occurrences. Standards: 8. Attempts shall be made to implement new or modified interventions as needed to enhance safety and consistent with root cause analysis; new interventions to be communicated to the facility staff through revision of resident care plan and profile to maintain continuity of care. Examples of Standards Fall/Safety Precautions that may be applicable: 10. Supervision of residents who require staff assistance with bathing, showering or toileting

Based on record review and interview the facility failed to implement initial fall precautions for high risk for of one of three residents (R1) all reviewed for high risk for falls. This failure has resulted in R1 falling from the bed and being admitted to the hospital for a dislocated left hip. Findings Include: Medical record documented R1 was [AGE] years old admitted to facility on 9/16/2015 at 2:40PM with [DIAGNOSES REDACTED]. She had history of hip fracture, Lumbar compression fracture and spinal fracture. According to record, R1 was admitted to facility for Rehabilitation status [REDACTED]. Fall risk assessment completed on 9/16/2015 at 3:27PM by E5(Registered Nurse, RN) documented a score of 12 (high risk for falls) On 9/16/2015 at 4:00PM, nurse's note documented R1 was transferred to another floor in facility. On 9/16/2015 at 6:13PM, E6(Licensed Practical Nurse, LPN) wrote R1 was observed on floor in room and complained of pain to left hip. R1 was medicated for pain according to nurse's note. Nurse also documented at 6:25PM, that Physician and family were made aware. Physician gave orders to send R1 to emergency room . The ambulance service was called and arrived at 7:05PM. At 12:29AM on 9/17/2015, nurse wrote that R1 was admitted to hospital with [DIAGNOSES REDACTED]. On 12/15/2015 at 9:15AM, E1(Administrator) said she was aware that R1 was high risk for falls and the family had agreed to be with R1 twenty four hours daily for the duration of R1's stay at facility. E1 said she could not remember who communicated that information to the nurse prior to R1's admission. However, she said Z2 (Family member) was here at facility and did not inform them when he left. Facility is a skilled care facility that employs staff to provide service to residents. On 12/15/2015 at 9:40AM, Z2 said he was at facility when R1 was admitted . He said the ladies who were taking care of R1 told him to go home and get regular clothes for her. Z2 could not remember their names, however, he said they were aware that he left as he told them he will take a shower and will be back to spend the night. Z2 said he agreed to be at facility with R1 because she was independent prior to hospitalization and thought she was still independent. He said R1 does not follow instructions all the time because she was forgetful. When asked if this information was told to facility, Z2 said he had conversation with Social Worker at facility( no longer employed there per E1) and that was the reason he planned to stay at facility with R1. He said he did not want her to fall because her bones gets fractured even without a fall. Patient Transfer report from hospital from Physical Therapist on 9/15/2015 noted that R1 needed assistance for mobility and transfer. Fall precaution was clearly listed on Discharge summary from hospital. On the Cognitive Status Examination from the hospital on [DATE], R1's cognition was oriented to person , place and time but forgetful, Has poor short term memory, follows 75 percent of commands and Personal Safety and judgement was impaired. On 12/15/2015 at 3:03PM, E5(Registered Nurse, RN) said she knew that because R1 had a new hip replacement that she was high risk for falls and the fall risk assessment done on 9/16/2015 scored 12 which was high risk. E5 said the call light was in place and the bed was low. E5 said she did not have a chance to review all of R1's transfer papers from the hospital and not aware of R1's cognition except she was alert and oriented x3. She said the restorative nurse is the one who will assess the patient further and implement alarms or whatever else is needed to prevent fall. On 12/16/2015 at 9:35AM,E6(Licensed Practical Nurse, LPN) said she received R1 to the first floor but never received a report from the nurse on the third floor and was not aware that R1 was high risk for falls. According to E6, she introduced herself to patient and left out the room. E6 said she did not get back to the resident until she was summoned to the resident's room because she fell . E6 said if she had known that R1 was high risk for falls she would have put interventions in place besides the call light and low bed. She said she would have monitored her closer. On 12/16/2015 at 10:00AM, E7(Restorative Nurse) said she was not the one to put immediate interventions in place for fall prevention. However, she said it was the nurse's responsibility to provide interventions needed immediately. On 12/16/2015 at 9:00AM, E1 said they do not have a policy for alarms, however, she said that since R1 was alert and oriented x3, she was not appropriate for bed or chair alarms. When asked if she knew that R1 was forgetful, had impaired short term memory and her safety awareness cognition was impaired she did not respond. On 12/16/2015 at 10:35AM, Z1(Physician) said he had never met R1. However, he said if the facility could not provide one on one care for a resident who needed to have one on one care, then the facility should not have accepted the resident. Facility's policy on fall dated 3/2015 noted, The program will include measures which determine the individual's needs of each resident by assessing the risk for falls, and implementation of appropriate interventions to provide necessary supervision and assistive devices and utilized as necessary. Safety interventions will be implemented for each resident identified at risk using a standard protocol. Facility's policy on Admission of Residents dated 12/2013 noted ,Review residents' personal data with resident and family to be sure that all information on the Admission Notice is correct and current. Facility's undated policy on Transfer of Resident Within the Facility (b) of #5 noted,Transfer the following with the resident,Any resident specific care information such as fall reduction program, or care reminders.

Based on interview and record review, the facility failed to provide adequate supervision for one of five residents (R4) who required toileting assistance with supervision due to ADL (Activities of Daily Living) and Self-Care Performance Deficit related to limited mobility and failed to follow their Fall Reduction Program policy and procedure. This failure resulted in R4 falling off the toilet while unsupervised resulting in admission to hospital with a right hip fracture and open reduction and internal fixation of the right hip. Finding Includes: The face sheet indicates R4 is [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Sets date 11/24/14: Section C0500 Summary Score is 05 (00-15), C1000) Cognitive skills for daily decision making blank. C1300 Sign and Symptoms of Delirium coding (B). Disorganized thinking - Was the resident's thinking disorganized or incoherent was score 2 (rambling or irreverence conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)? The Functional Status Section G: (B): Transfer score was 3/3 (Extensive assistance -resident involved in activity, staff provide weight-bearing support and Two plus person physical assist). Section: G0300 and 0400: Balance During transition and walking and Functional Limitation in range of motion score was 2/2 (not steady, only able to stabilize with staff assistance and impairment on both sides). The progress notes date 12/03/14 at 4:00pm indicates resident was on the toilet, and this writer heard resident voice went to her room and found resident on floor lying by the toilet. This writer assessed, but resident was not able to move her right leg complaining of pain. Supervisor and Director of Nurses made aware. Resident was transferred to bed immobilized long rolled. The medical Physician notified and ordered transfer to hospital. Z3 (hospital) progress notes dates 12/04/12 indicates Resident suffered unwitnessed fall in the bathroom yesterday (12/03/14). X- Ray of right hip imaging revealed intertrochanteric fracture. She also was noted to have new onset atrial fibrillation, evaluated by cardiology. Z4 (Consult -Orthopedic) date 12/07/14 indicates resident needed surgery for [REDACTED]. The employee report date 12/04/14 indicates on the date E7 placed a resident in the bathroom alone with a history of Dementia, Weakness, Depression. Unattended the resident the resident attempted to get up and fall resulting in a right hip fracture. Because of the seriousness of the injury which could be avoided we the facility fell s dismissed is necessary. E7 (Certified Nurse Aide) on 12/26/14 at 12:43pm states I put her (R4) on toilet. I told her push the call light. I told her I would come back and check on her. I went attended the needs of another resident. I heard shouting from the outside the room and when I got back R4 was on the bathroom floor. She usually does not get off the toilet. She needs assistance in transfer. E8 (Nurse) on 12/26/14 at 1:43pm states I heard shouting and went to the patient room and found her sitting on the floor near the toilet. She complained of pain on her right leg. I immobilized the area, administered pain medication and call the doctor. I got order to send out to the hospital. The Fall Reduction Program Policy and Procedure: The standard Fall/Safety Precaution: All Resident: (10). Residents who require staff assistance will not be left alone after being assisted to bath, shower or toilet.

Based on interview and record review, the facility failed to have a formal agreement or method for communicating with the [MEDICAL TREATMENT] staff regarding the care and services for four of four residents (R1, R7, R8 and R9) reviewed for [MEDICAL TREATMENT], in a sample 15. As a result, a [MEDICAL TREATMENT] resident (R7) bled out and died , when the facility failed to follow their policy for monitoring the site. Findings include: R7 ' s electronic medical record [DIAGNOSES REDACTED]. On [DATE] at 9:29a.m, Z2 (daughter) stated she called the facility on [DATE] around 5:05 am to check up on (R7) because she sensed something going wrong with (R7). Z2 stated when she called no one picked up the phone, she called again and E12 (night nurse supervisor) picked up, E12 told to her that she will go up to R7 ' s floor to ask E5 (Nurse) to pick up the phone. Z2 stated she was on hold till E5 picked phone. Z2 stated that E5 informed her that R7 was " fine. " Z2 stated in part that the next call she will get was from the local hospital emergency doctor who called her to inform her that (R7) is in the hospital for emergency care of the [MEDICAL TREATMENT] access line and that R7 has lost a lot of blood. On [DATE] at 12:55pm, Z4 RN (Registered Nurse) [MEDICAL TREATMENT] nurse, Z9 and Z10 ([MEDICAL TREATMENT] Technicians) in the home [MEDICAL TREATMENT] unit stated R7 has been known to remove her AV-Fistula access site dressing prior to incident of [DATE]. Z4, Z9 and Z10 were unable to present any documentation that communicate this behavior to the nurses on the floor, resulting in lack of assessment and appropriate monitoring for R7. Z4 stated in part that everyone is aware of this, Z4 turned to Z9 and Z10 ([MEDICAL TREATMENT] Technicians) to corroborate her statement stating " Isn ' t that so. " And both Z9 and Z10 replied " yes. " On [DATE] at 10:45am, Z3 (Nephrologists) stated in part that it is not advisable to allow R7 to remove her Av-Fistula by self because since (R7) was not trained to perform this task and if much pressure is applied when removing the dressing can result in hemorrhage (bleeding). On [DATE] at 1:25p.m., E3 DON (Director of Nurses) stated in part that it was reported to him that R7 was scratching the AV-Fistula sight and removing the dressing at the Av-Fistula site but it was not treated as a behavior. On [DATE] at 11:03am, E15 CNA (Certified Nurse ' s Aide) stated in part that on [DATE] when she came on duty for 11pm to 7am shift (R7) was already asleep and (R7) did not require much help. E15 further stated in part that she saw (R7) but at 5:25am when (R7) called for the light to be turned off after (E15) left it on after caring for (R7) ' s roommate. On [DATE] at 3:12pm, E5 (Nurse) acknowledged that when he came on duty he saw (R7) at 11:10pm and (R7) was sleeping. E5 further stated he did not physically check on (R7) ' s AV-Fistula for patency (thrill and bruit). E5 also stated at 5:30am, he found (R7) on the floor in the room bleeding from the [MEDICAL TREATMENT] site (AV-Fistula)with about ,[DATE]ml (Milliliters) of blood on the floor and the AV Fistula dressing was off. On [DATE] at 11:55am, E1 stated in part that removing her dressing is not considered behavior because that is R7 ' s preference. At 12:00pm, E3 acknowledged being informed of the issue with R7 tampering with the Av-Fistula dressing prior to incident of [DATE] stating "We did not treat that as behavior and that does not need to be documented. " R7 ' s care plan presented by the facility with problem date of [DATE] and edited date of [DATE] is not individualized to R7, no mention of checking for patency of Av-Fistula line, no care plan developed to address the removing of Av-fistula line dressing. The facility " Behavior Symptom Evaluation policy " presented with no date under the title definition indicated that any behavior including but not limited to removing of bandages and tapes " should be considered for behavior coding and interventions if they become consistent, that is part of the individual ' s repertoire. " The facility " behavior symptom Evaluation policy " presented further indicated under documentation " Documentation shall occur according to the facility ' s policy. This includes a " Special behavior Symptom Evaluation " within the appropriated time parameters and subsequent follow up documentation. A care plan addressing the behavior symptoms and interventions is recommended. This policy was not followed. Review of the electronic record of R1, R7, R8, and R9 had no form of two way communication between the [MEDICAL TREATMENT] staff and the facility staff. On [DATE] at 12:55pm, Z4 stated any information about the resident is communicated to the floor nurses verbally. On [DATE] at 11:56am, E13 (Social services Director) stated in part that she was not aware of (R7) ' s behavior of removingthe AV-Fistula site dressing. At 12:08pm, E14 (Social Services Aide) assigned to R7 also stated he was not notified of this behavior. On [DATE] at 10:00am, E3 stated " communication between [MEDICAL TREATMENT] staff and floor nurses are done verbally by telephone calls. The facility [MEDICAL TREATMENT] contract indicated " The personnel shall maintain communication with the facility ' s Director of Nursing during the [MEDICAL TREATMENT] treatments and shall immediately inform the facility ' s nursing staff of any change in the patient condition requiring immediate nursing or medical attention.

Based on observation, interview and record review, the facility failed to follow the assessment for safe transferring of a resident; failed to conduct an investigation to determine cause of a resident fall and revise care plan intervention to address multiple falls to prevent injury. This failure affected 1 of 4 residents (R1) reviewed for falls in a sample of 12. As a result of the failure R1 experienced two falls and each resulted in fracture of the left fibular head and fractured right distal femur. Findings include: On 7/21/14 at 11:53am, E3 DON (Director of Nurses) stated on 4/03/14 (R1) went out on pass and sustained a fall went to emergency room for care and the X-ray done at the time was negative for fracture, after returning to the facility (R1) started complaining of pain and was sent to the local hospital for MRI (Magnetic Resonance Imaging) on 4/08/14. R1's electronic medical progress note dated 4/4/14 3:43pm by E7 (Registered Nurse) documented she was informed to get ortho doctor ' s appointment because R1 had a mild fracture on the left fibular head. This information was endorsed to the supervisor and all shift (referring to staff). Documentation in the progress note indicated the result faxed to the facility on [DATE] at 11:03am. The State Agency was not notified until 4/11/14 at 5:39pm, over 23hours. On 9/08/14 at 4:27pm, E3 DON (Director of Nurses) acknowledged Z11 (physician) on 4/04/14 called the facility to inform them of R1 x-ray result showing the fracture of the left fibular head. R1's care plan was not updated between 4/3/14 and 7/09/14 to address R1's fracture and no preventive measures documented to prevent further injury. R1's progress notes indicated R1 complained of pain to lower extremities on 7/04/14 at 5:40am while being transferred from bed to wheelchair with one person staff assistance. R1 was sent to the hospital for X-ray which shows that R1 had fractured her right distal femur. R1's hospital medical record documented admission [DIAGNOSES REDACTED]. On 7/18/14, R1's MDS (Minimum Data Set) presented dated 1/28/14 and 4/21/14 coded under transfer 3/3, indicating that R1 needs extensive assistance with two person physical assistance. R1 ' s care plan did not address this issue. R1's physical therapy recommendation dated 5/27/14 documented recommendation of use of sliding board with minimal assistance. Care plan does not reflect use of sliding board. On 7/21/14 at 3:12pm, E10 (CNA/Certified Nurse's Aide) acknowledge transferring R1 from bed to wheelchair by herself using gait belt when R1 pushed her away started shouting and was complaining of pain to her leg on 7/4/14. On 7/22/14, R1's care plan with problem start date 1/15/14 with approach start of 10/19/12 did not mention any monitoring, after the fall of 4/3/14 care plan showed revised date of 4/29/14, 15 days after the fall and fracture without any new approach indicated and a fall care plan dated 7/05/14. R1 ' s care plan did not show documented revision plan of care till after the fall of 7/4/14. On 7/21/14 at 12:55pm E16 (Care Plan Coordinator) stated the in part that the revision of care plan was done quarterly and that is why R1 ' s care plan is not revised after the fall of 7/4/14. On 7/21/14 at 3:21pm, E19 (RN) acknowledge that R1 needs at least 2 person physical assist to transfer and at the time of R1 ' s fall " I did not see any gait belt on E10 and E10 transferred R1 by herself. " On 8/22/14 at 11:25am, E9 (Director of Restorative Services) acknowledged that after the fall of 4/3/14 (R1) should be transferred using 2+ person assistance stating " Looking at the MDS (Minimum Data Set) dated 4/18/14 (R1) still needs 2+ assistance in transferring before 7/4/14 incident, one person assist is not appropriate in transferring as MDS coded. " On 8/22/14 at 12:55pm R1 was noted in the dialysis unit with dialysis on going through left arm AV-Fistula, R1 stated " (E10) dropped me on the floor when she was pulling me up from my bed to get me into the chair, (E10) did not use any belt none of them use it but they do now. (E10) knows she needs help to get me up because I had a broken leg and I can ' t use that leg well. " The facility comprehensive care plan policy and procedure presented with no date indicated " Care plans are revised as change in the resident ' s condition dictates. " The facility fall prevention policy with no date indicated under fall prevention that " Residents that are identified as at risk for falls, clinically appropriate interventions will be put in place to reduce the risk for falls and /or prevent recurrence of falls. " The fall reduction Program with revised date 12/2013 indicated in part that the program will include measures which determine the individual needs of each resident, and care plan will incorporate identification of all risk/issues, addresses each fall and change intervention with each fall as appropriate and preventive measures. The facility Fall reduction policy further indicated: " Accidents/incident Reports (on paper) of falls events involving falls will be reviewed by the Director of Nursing and the administrator to ensure appropriate care and services were provided and determine possibly safety interventions. " The policy further indicated the IDT (Inter disciplinary team) will review after each fall, and changes will be made to the plan of care, resident will be assessed for changes in condition post fall (72 hrs post fall), care plan will be reviewed and revised as indicated. These policies and procedures were not fully followed.

A) Based on observation, interviews and record reviews, the facility failed to consistently and accurately assess, monitor, and prevent the development of recurring pressure ulcers for 1 resident (R29) out of the sample of 30 reviewed for pressures ulcers. This failure resulted in R29 becoming septic and required hospital admission for surgical debridement. Findings include: R29 was an [AGE] year old who has multiple medical [DIAGNOSES REDACTED]. On [DATE] at at 4:10 PM, Z2 (Wound Care Doctor) stated he never had residents dying of a pressure wound, residents may have died with a pressure wounds, but not because of the pressure wounds. Z2 remembers R29 as having multiple pressure wounds but [MEDICAL CONDITION]. Z2 defined [MEDICAL CONDITION] as having no odor, no drainage and no redness. On [DATE] at 9:30 AM, Z6 (R29's son) stated over the phone, they were never notified regarding R29's multiple bedsores, especially the development of a Stage IV pressure sore on the hip, until R29 went to the hospital. Z6 added he and his siblings were told by the doctor from the hospital that R29 [MEDICAL CONDITION] related to the extremeness of the bed sore on her hip and that it was part of her decline. On [DATE] at 10:20 AM, E3 (wound care nurse) stated R29, as far as she recalled, the right and left ischial ulcer developed sometime in December. It was healing. R29 went to the hospital with a stageII ulcer on the right ischium (lower back/ back part of hip bone). Review of R 29's Treatment Administration Record indicated: Right Ischium; Cleanse with normal saline solution, apply [MEDICATION NAME] to open wound only and cover with [MEDICATION NAME] dressing. Change dressing 2 times a week and as needed for soiled dressing. Comprehensive skin assessments to right ischium was done only 3 times from [DATE] to [DATE]. - [DATE] assessment indicated; a stage II ulcer, no exudates, no odor, and normal skin intact. The size (Length x Width x Dept) was 2.7 x 2.1 x .1 centimeter (cm). - [DATE] assessment indicated; a stage II ulcer, scant serosanguinous exudate, no odor, and skin macerated. The size was 2.7 x 2.1 x 0.1 cm. - [DATE] assessment indicated; a stage II ulcer, no exudate, no odor, and skin attached. No further comprehensive skin assessment was made after [DATE]. E2 (Director of Nursing/ DON) stated on [DATE], comprehensive skin assessments should be done quarterly for residents with no wounds, and weekly for residents with wounds. Review of R29's progress notes indicated: -[DATE] at 9:33 AM, E3 documented- Right Ischium is deteriorating, it is now unstageable and 100% slough. -[DATE] at 12:02 PM, E3 documented (recorded as late entry on [DATE] at 12:06 PM). Right Ischium is healed. -[DATE] at 1:37 PM, Z2 documented - Healed Ischium. There was no pressure wound care plan found in R29's list of care plan. [DATE] at 4:39 PM, E26 Nurse Practitioner, documented- chief complaint of R29: lethargic, very weak, decreased appetite. Necrotic wound right ischium. Fever, suspected [MEDICAL CONDITION]. [DATE] at 5:15 PM, R29 sent to the hospital for further evaluation and treatment. Review of R29's hospital record indicated, R29 came in to the hospital on [DATE] with a stage IV pressure ulcer on the right buttock. Upon assessment of the right ischium wound was described with a measurement of 3 cm x 5.6 cm, 98% eschar, reddened surrounding tissue, blanchable and positive odor. R29 [MEDICAL CONDITION] related to this wound, was given anti- biotic therapy and had underwent surgical debridement on [DATE]. The facility's wound care nurse's assessments were inconsistent with the hospital's assessment and treatment of [REDACTED]. B) Based on observation, interview, and record review, the facility failed to monitor and document pressure sore monitoring for 1 resident (R15) from the sample of 30 reviewed for pressure sores and failed to pad the air mattresses with the appropriate amount of linens for 5 residents (R2, R4, R6, R15, R16) in the sample of 30 and 4 residents (R31, R32, R34, R35) in the supplemental sample reviewed for pressure sore relief interventions. Findings include: On [DATE], at 12:40pm, E3 (Treatment Nurse) performed wound care to R15's Stage II sacral pressure ulcer, measuring 0.6 x 1.1 x 0.1 cm. E3 stated that this is the same area of breakdown that has been there since it was discovered as a Stage I pressure ulcer on [DATE]. At this time, there were 4 layers of linen on the air mattress. Record review includes: R15 was readmitted to the facility on [DATE] with documented redness to the coccyx, no measurements given. On [DATE] Weekly Wound Note documents a Stage I sacral pressure ulcer measuring 5.5 x 6.5 x 0 cm, skin intact, non-blanchable redness. On [DATE] Weekly Wound Note documents an open Stage II sacral pressure ulcer measuring 1 x 1.1 x 0.1 cm. There is no evidence of skin assessments or wound monitoring for the 9 days in between the two wound notes dated [DATE]/ and [DATE]. E2(Director of Nursing) verified on [DATE] at 11:30am that no evidence was found regarding wound monitoring or skin assessments for R15. On [DATE], at 1pm, E3 also stated that there is no documentation of R15 ' s sacral wound condition or skin assessment between [DATE] and [DATE]. Z2 (Wound Care Doctor) stated in a progress note that the 6 layers found on R15's bed on [DATE] caused the worsening of the sacral wound from a Stage I to a Stage II. Facility policy titled Pressure Ulcer Prevention Protocol states that all residents will have their skin checked and measurements performed at a minimum of weekly. On [DATE], from 9:45am to 11:05am the following was found: -R34 ' s air mattress was covered with 11 layers - a fitted sheet, a draw sheet folded in fourths, a comforter, another draw sheet folded in fourths, and an incontinent pad. E7 (Nurse) stated that R34 sleeps on top of all these layers during the day. E7 also stated that there should only be 2 layers of linens on the air mattress. - R35's air mattress was covered with 8 layers - a fitted sheet, a draw sheet folded in fourths, a flat sheet, a blanket, and an incontinent pad. - R4's air mattress was covered with 6 layers - a fitted sheet, a draw sheet folded in fourths, and an incontinent pad. - R31's air mattress was covered with 5 layers - a fitted sheet and a draw sheet folded in fourths. - R15's air mattress was covered with 3 layers - a fitted sheet and a draw sheet folded in half. -R32's air mattress was covered with 3 layers - a fitted sheet and a draw sheet folded in half. On [DATE], at 11:40am, E7 stated that there should only be 2 layers of linens on the air mattress; E3 also stated that there should only be 2 layers of linen on the air mattresses. On [DATE], at 1:40pm, Z2 (Wound Physician) stated that there should only be 2 layers of linens on the air mattresses because the mattress needs to stay soft. Too many layers make the mattress surface hard and stiff which could cause worsening of a wound and delay healing. Z2 stated he told the staff on [DATE] that there should only be 2 layers on top of the air mattress. Manufacturer handout for the air mattress used at the facility states that multiple layers of linen or pads beneath the resident can negatively affect the mattress ' s pressure management capabilities and should be avoided unless recommended by a caregiver. R16 has [DIAGNOSES REDACTED]. On [DATE] at 3:00 PM, R16 was noted lying in bed on a pressure reduction mattress. R16 wore an incontinence brief and beneath that brief the mattress was covered with an incontinence pad and a sheet. On [DATE] at 10:00AM, R2 was noted lying on an air mattress with a fitted sheet, a flat sheet folded in fourths and a thick incontinence pad. R2 has documented sacral pressure sores. E41 (Nurse's Aide) stated on [DATE] at 11:00AM that she has been working in the facility for one year, and this is the way she was taught. The multiple padding is the way it is done here. On [DATE], at 11:40am, E7 stated that there should only be 2 layers of linens on the air mattress; E3 also stated that there should only be 2 layers of linen on the air mattresses. On [DATE], at 1:40pm, Z2 (Wound Physician) stated that there should only be 2 layers of linens on the air mattresses because the mattress needs to stay soft. Too many layers make the mattress surface hard and stiff which could cause worsening of a wound and delay healing. Z2 stated he told the staff on [DATE] that there should only be 2 layers on top of the air mattress. Manufacturer handout for the air mattress used at the facility states that multiple layers of linen or pads beneath the resident can negatively affect the mattress's pressure management capabilities and should be avoided unless recommended by a caregiver.