Every finding on record at Elevate Care South Holland

Based on observation, interview and record review, the facility failed to provide adequate safety and supervision to prevent one resident (R1) from falling from the bed while receiving care and one resident (R2) from falling while attempting to independently retrieve ice in the dining room in a sample of three residents reviewed for falls with injury. These failures resulted in R1 and R2 sustaining left hip fractures requiring hospitalization and surgical intervention. Findings include: R1 is [AGE] years old and was originally admitted to the facility 8/2/2020 with diagnoses that included cerebral infarction, hemiplegia and hemiparesis affecting left side, hypertension, heart failure and weakness. Minimum Data Set (MDS) dated [DATE] assessed R1 to be cognitively intact and dependent on staff to receive care due to impaired mobility.Facilty fall incident dated 6/27/26 at 4:30am stated: Writer was called to the resident's room by staff who was providing care. Staff reported that the resident slid to the floor. Upon assessment, the resident stated she hit the left side of her head and complained of pain to the left side of her body. The root cause analysis of the incident stated, Resident slid out the bed during care. Interventions included: Upon return resident will have fall mats, bed bolster, and 1/4 side rails for bed mobility.R1 was sent to the hospital via 911 for evaluation.Hospital records indicated R1 was admitted [DATE] with diagnosis of a left hip fracture requiring surgical intervention and returned to the facility 6/30/26.On 8/22/26 at 12:07pm R1 was in bed, alert and coherent to self, place time and situation. Half side rails were in place on the bed and fall mats were placed to each side of the bed. R1 said, someone came in while I was sleeping when I fell out the bed. R1 said at first, I thought I was dreaming but soon realized I was really sliding and started screaming I'm falling! R1 said a staff person in the room kept saying 'you're not falling, you're not falling'- and then R1 hit the floor hurting the left side. R1 said they were sent to the emergency room and had surgery on the left hip with screws placed in the bone and staples to the leg. R1 said that a follow up was scheduled for September 2026.On 8/23/26 at 4:04pm V6 CNA (Certified Nursing Assistant) said R1 is dependent for all activities of daily living. V6 said when R1 fell, V6 was in the room to provide incontinence care to R1. V6 said they did not work with R1 regularly but felt comfortable repositioning and provide care to R1 without the assistance of another staff member. As V6 was gathering supplies, R1 began sliding off the bed and V6 said they didn't notice R1 was sliding until R1hit the floor. V6 said, if they had noticed, they would have been able to hold R1 and prevent the fall from occurring.On 8/23/26 at 2:40pm V5 Restorative Nurse said, because of R1's medical history of cerebral infarction, R1 has poor trunk control and is not able to turn or sit up independently. Additionally, R1's left side is weak and the left arm is contracted. Because of these functional deficits, it would have been difficult for R1 to stop herself from sliding. V5 said prior to the fall on 6/27/26, R1 had general interventions in place because R1 did not have any documented falls since admitting in 2020. V5 said, when residents suffer a fall, the root cause is analyzed to determine the appropriate prevention measures for any subsequent falls and to minimize potential injury. V5 said, because R1 fell out of bed while receiving care from staff, the interventions added would not have prevented R1 from sliding out of bed. R2 is [AGE] years old and admitted to the facility 1/22/26 with diagnoses that included vascular dementia, major depressive disorder, malnutrition, pulmonary fibrosis and spinal stenosis. MDS dated [DATE] indicated that R2 was unable to walk 10 feet and required maximal assistance to wheel 50 feet in a manual wheelchair.Fall incident reported 5/3/26 at 4:18pm stated R2 had an unwitnessed fall while in the dining room. Resident stood from wheelchair to get ice from the ice machine and fell while returning to seat. Injuries Observed at Time of Incident: face laceration.Hospital reports dated 5/3/26 indicated R2 was transferred to the emergency room for head imaging. R2 returned to the facility after the emergency room assessment.Facilty reported incident of 5/5/26 stated R2 was complaining of pain while receiving nursing care. An X-Ray was obtained of the lower extremities resulting in left hip fracture. R2 was transferred to the hospital and received surgical intervention for the injury. R2 returned to the facility on 5/10/26.On 8/23/26 at 12:36pm R2 was sitting on the bed, eating independently. R2 was alert and conversive, with some confusion. R2 rubbed the left leg and said it hurt very much. R2 could not remember information regarding the fall incident. A foam hip abductor pillow was noted on top of the wardrobe.On 8/22/26 at 4:40pm the ice machine was identified to be stationed inside of a large room on the third floor. Double doors separate the large room from an open sitting area in front of the nurse's station. V8 CNA was observed in the sitting area positioned to view all of the residents seated in the vicinity. V8 said the larger room is used for activities and dining, although lately, the tables have been moved to the sitting area to make it easier for the residents to be seen by staff. CNAs sit in 30-minute schedules in the area to watch the residents while they are occupying the room. V8 said residents are not allowed to go into the large room unattended because it is not safe.On 8/23/26 at 1:14pm V7 CNA said they were monitoring the Dining Room when R2 fell. V7 said the incident happened sometime before dinner. V7 did not see R2 enter the dining room. V7 heard a noise, looked up and saw R2 was on the floor with R2's wheelchair beside. V7 said if they had noticed R2 was attempting to get ice or water, they would not have allowed R2 to get it independently because R2 it was not safe for R2 to be standing up from the chair without assistance.On 8/22/26 at 5:16pm V2 DON (Director of Nursing) said that the CNAs are assigned to take turns in 30-minute increments to monitor the dining room and sitting area. This is intended to provide staff supervision when residents are occupying the room. The CNA watching the dining room at the time R2 fell should have seen R2 getting ice and offered to assist. Before the fall, R2 was a little more independent with mobility and is now totally dependent on staff.MDS dated [DATE] post fall incident indicated that R2 was unable to walk and was totally dependent on staff.

Based on observation, interview, and record review, the facility failed to follow policy and procedure; failed to document the administration of medications (controlled substance); and failed to document in a resident's medical record a fall with serious injury in a timely manner. These failures affected one resident (R1) of three residents reviewed for falls.Findings include:R1's face sheet documents and admission date of 3/21/25 and diagnoses that include but are not limited to tracheostomy, artificial opening of urinary tract, malignant neoplasm of abdomen, secondary malignant neoplasm of bladder, retention of urine, urogenital implants, and dysphagia.R1's BIMS (brief interview for mental status) score, dated 4/16/26, is 13 which indicates R1 is cognitively intact.R1 unable to be interviewed due to R1 being hospitalized as of 5/26/26.R1's progress note, dated 5/25/26 at 9:00pm; created date 5/26/26 at 9:16am, (over 12hours after R1's fall occurred) per V6 (Registered Nurse/RN), documents, in part, Pt (R1) noted to be alert x2-3 with confusion noted pt (R1) has hx (history) of anxiety requiring meds, recent falls and cancerous mass to right side hip contributing to impaired mobility and high fall risk. Pt (R1) frequently forgets and requires repeated reminders not to get out of bed without assistance, despite education and reinforcement of safety instructions. Pt (R1) attempted to get out of bed unassisted. Fall precautions remains in place including lowest bed position call light within reach nonskid footwear door opened for frequent rounding. Pt (R1) assessed no skin tear or bruise noted. Pain medication provided. Wife notified. V6's (Registered Nurse/RN) narrative was not documented in a timely manner (over 12 hours from the date and time of R1's fall).R1's Initial FRI (Facility Reported Incident), 5/27/26, documents, in part, Incident date: 5/27/26; Incident Category: Fall with physical harm or injury; R1 was observed on the floor. No change in LOC (level of consciousness) with baseline. Full body assessment completed, no visible injuries noted. No s/s (signs/symptoms) of pain manifested as of fall. Neuro check initiated. ROM (range of motion) was done to all extremities and were WNL (within normal limits). No lengthening/shortening of limbs noted. MD (medical doctor) notified, Family notified. R1 complained of pain, V9 (Nurse Practitioner) assessed R1 and noted abnormality to right lower extremity. Order received to transfer resident to ER (emergency room) for further thorough evaluation. Bed in low position, call light attached within reach and not triggered. POA (power of attorney) was notified of transfer. POA was agreeable to plan of care. R1 is admitted to hospital with diagnosis of Right Hip Fracture.On 6/5/26 at 3:10pm, V6 (Registered Nurse/RN) said, I was his (R1) nurse. R1 was found on the floor in a sitting position. He's (R1) right by the nurse's station, but we (staff) didn't get to him (R1) in time to prevent the fall. I assisted him (R1) to bed. Did an assessment. He (R1) was in pain, but he (R1) was pointing to the mass side for cancer. The same type of pain that R1 always complains of, not worse. Called family and physician and let them what's going on. That was the first time doing protocol for facility. I should have charted the incident as soon as it happened. I charted the fall in the morning cause I picked up a shift. My note should have been more descriptive. There's a lot that goes on and you rush and try to remember to do everything, I left at 11:30pm. I charted the paper when I gave him (R1) the narcotic. No, I didn't chart it in PCC (electronic documenting system). I administered it (Tramadol). I just wrote it down. Yes, I should have charted the pain medication in PCC.Record review of R1's, May 2026, Medication Administration Record (MAR) revealed no documentation indicating that R1 received Tramadol following the fall that occurred on 5/25/26 at approximately 9:00pm. The MAR further documents that R1 did not receive any dose of Tramadol on 5/25/26. Documentation reflects that Tramadol was subsequently administered on 5/26/26 at 9:46am, prior to R1's transfer to the hospital.Record review of R1's Controlled Drug Receipt/Record/Disposition Form revealed documentation indicating that Tramadol was removed from R1's medication stock on 5/25/26 at 9:00pm. However, there was no documentation to indicate that the medication was subsequently administered to R1.On 6/6/26 at 10:07am, V2 (Director of Nursing/DON) said, Yes, I expect them (nursing staff) to do a detailed narrative and in a timely manner, when there is an incident like a fall, even if it's not a serious injury. We (facility) have to QA (Quality Assurance) falls and find causes and put interventions in place. No, V6's note for R1's fall does not describe what happened or could have happened. When giving controlled substances, they are supposed to be charted in the MAR (medication administration record) and not just signed off on the controlled sheet. They've been in-serviced on this.Record review of facility policy titled, Medication Administration Policy, dated 1/1/2015, documents, in part, Medications shall always be prepared, administered, and recorded by the same licensed nurse. Documentation of medication administration is recorded on the Medication Administration Record (MAR) or Treatment Record and includes the date, time, and initials of the licensed nurse who administered the medication. Class II Medications: Only a licensed nurse may - a) administer Class II medications and/orb) handle, carry, and/or use the controlled medication key. When Class II medications are administered, the medication is recorded on the Medication Administration Record by a licensed nurse.Record review of facility policy titled, Fall Prevention Program, dated 11/21/17, documents, in part, To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. The Fall Prevention Program includes the fallowing components: Assessment time frames; Use and implementation of professional standards of practice.Record review of pamphlet titled, RESIDENTS' RIGHTS' For People In Long-Term Care facilities, revised date 11/18, documents, in part, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis. You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally, or sexually. Your facility must be safe, clean, comfortable, and homelike.

Based on interview and record review, the facility failed to ensure that staff follow professional standards of practice of carrying out physician orders for one resident (R3) and failed to document resident assessment in medical record for five residents (R2, R3, R4, R5, R6) These failures affected five residents (R2, R3, R4, R5, R6) of six residents reviewed for nursing care, and have the potential to affect all 125 residents at the facility.Findings include:R3 is [AGE] years old and has resided at the facility since 2023, past medical history includes : Alzheimer's disease unspecified, encounter for attention to gastrostomy, adult failure to thrive, hypothyroidism, unspecified convulsion, malignant neoplasm of left kidney except renal pelvis, pressure ulcer of right elbow stage 3, pressure ulcer of sacral region stage 4, fall on same level from sipping, tripping and stumbling, essential primary hypertension etc.On 4/7/2026 at 3:49PM, V19 (Infectious Disease Nurse Practitioner) said that she is familiar with R3 and has been in his case since January. R3's wound was infected as indicated in January wound culture. R3 had a debridement recently and has been on antibiotics since January. V19 said that she ordered a repeat wound culture but do not think it was collected.Review of medical records showed wound culture dated January 16, 2026, that was positive for Klebsiella pneumonia and Enterococcus faecalis. Review of physician orders for R3 showed three orders to obtain wound culture by V19 dated 2/7/2026, 2/18/2026 and 3/18/2026.On 4/8/2026 at 3:15PM, V2 (DON/Director of Nurses) said that they do not have the result for the wound cultures ordered for R3 on 2/7/2026 and 2/18/2026 because they were not completed, resident was at the hospital on 3/18/2026 and that order could not be completed. The purpose of the blood culture is to get appropriate antibiotics for resident's wound, the ordered culture should have been collected, it is not standard of practice not to follow physician's order. V2 spoke to the two nurses that received the orders, they do not have any reason why they did not carry out the orders. The expectation is for the order to be carried out, cannot give a definite reason why the orders were confirmed when they were not carried out.R2 is 65 years and has resided at the facility since 2024, face sheet listed the following past medical history: quadriplegia C5 to C7 incomplete, encounter with attention to gastrostomy, type 2 diabetes, anxiety disorder, neurogenic bowel, retention of urine, etc.R4 is 91 years and have resided at the facility since 2023, past medical history includes : Unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, chronic kidney disease unspecified, altered mental status, hypokalemia, dysphagia oral phase, muscle wasting and atrophy, not elsewhere classified, multiple sites difficulty in walking , gastrostomy status, unspecified osteoarthritis, hyperlipidemia, etc.R5 is [AGE] years old and have resided at the facility since 2023, past medical history includes: Dysphagia following cerebral infarction, encounter for attention to gastrostomy, presence of cardiac implants and grafts, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, hyperlipidemia, essential primary hypertension, Alzheimer's disease, peripheral vascular disease, non- pressure chronic ulcer of left heel, diabetes mellitus, etc.R6 is 82 years and has resided at the facility since 2023. Past medical history includes, but not limited to pressure ulcer of sacral region stage 4, hypertensive heart and chronic kidney disease with heart failure stage 1 through stage 4, chronic systolic (congestive) heart failure, encounter for attention to colostomy, anemia unspecified, major depressive disorder, retention of urine, etc.Active physician orders for R2, R3, R4, R5, and R6 show the following order: Weekly Showers/Skin Assessment. Acknowledgment of shower and skin assessment completed. If new skin issue: notify physician for order, notify family and complete NUR Skin Assessment Form. Every day shift every Mon, Thu for Weekly Showers/Skin Assessment. If answer is NO to shower - document the refusal or resident being OOP or appt. If answer is YES to the new skin alteration - document, it under the NUR Skin Assessment Form.Review of shower sheets for the months of January, February and March for R2-R6 did not show any documentation of skin assessment, there was no documentation of skin assessment in any other part of medical record for these residents.On 4/7/2026 at 11:22 AM V18 (Wound Licensed Practical Nurse/LPN) stated that CNA (Certified Nurse Assistant) will call the nurse to do a skin check on each resident before their shower. If a bed bath is given, the nurses would still have done a head-to-toe assessment. V18 stated that the nurses only document their head-to-toe skin assessment on the CNA Shower Sheet. It is not documented anywhere else.On 4/7/2026 at 1:36PM, V20 (LPN/Treatment Nurse) said that nurses are supposed to do skin assessment as ordered and any skin alterations both old and new should be documented in shower sheets.On 4/7/2026 at 2:50PM, V2 (DON) said that showers are supposed to be completed according to the schedule and documented in medication administration record (MAR). Shower sheet is signed by nurses to show what is going on with the resident and collected by wound care. Nurses inspect the skin when shower or bed bath is given but are not required to document the condition of the skin in the shower sheet or resident's record. Nurses only have to put their initial in the medication administration record (MAR). V2 said that the facility does not have any policy stating that nurse's initial in the MAR is the only documentation required for skin assessment.Physician orders entering and processing policy revised 1/31/2026 stated its purpose as to provide general guidelines when receiving, entering and confirming physician or prescriber's orders. (a prescriber is noted as physician, nurse practitioner, and a physician's assistant).Guidelines: 5. Following a physician visit, a licensed nurse will check for any orders that require confirmation under clinical> orders>pending orders. The orders will be confirmed by the nurse and the instructions for the order will be completed.Job description for registered nurse (RN) and licensed practical nurse (LPN) (undated) stated in part: The RN/LPN is responsible for providing direct nursing care to residents and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state and local standards, guidelines and regulations that govern our facility, and --------------- to ensure that highest degree of quality care is always maintained.Essential duties and responsibilities:Complete and file required record keeping forms/charts upon resident's admission, transfer and /or discharge. Receive and transcribe telephone orders from physicians and record on the physician order form. Chart nurse's notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care.

Based on observation, interview and record review, the facility failed to ensure that staff provide scheduled shower for residents who were dependent on staff for Activities of Daily Living (ADL) and failed to ensure that skins assessments were completed and documented as ordered. This failure affected five residents (R2-R6) of five residents reviewed for ADL care.Findings include:On 4/6/2026 at 1:50PM R2 was observed in her room, awake, alert and oriented x2 to 3, stated she has been at the facility for about 3 years, the certified nurse assistants (CNAs) do not change her, she does not get out of bed only once in a while when they decide to take to the shower room. R2 said that she does not get her scheduled showers, gets bed bath most of the time but she would like to have showers because she likes water on her.On 4/6/2026 at 2:10PM, V5 and V4 (CNAs) walked into R2's room while the surveyor was talking to the resident, stating that they came to take her for a shower, she is scheduled on Monday and Thursday on Am shift. R2 said that the last time she had a shower was 2 weeks ago, the surveyor asked V4 and V5 the last time R2 was showered, and they both said they do not know. Both CNAs stated, the showers are documented on the shower sheet and placed in a binder at the nursing station.On 4/6/2026 at 3:09PM, V9 (R2's family member) said that R2 does not get her shower two times a week as scheduled, staff does not assist her with brushing her teeth, V9 has spoken to staff about the care R2 is receiving but nothing has changed.R2 is 65 years and has resided at the facility since 2024, face sheet listed the following past medical history: quadriplegia C5 to C7 incomplete, encounter with attention to gastrostomy, type 2 diabetes, anxiety disorder, neurogenic bowel, retention of urine, etc.Active physician order for R2 reads as follows: Weekly Showers/Skin Assessment. Acknowledgment of shower and skin assessment completed. If new skin issue: notify physician for order, notify family and complete NUR Skin Assessment Form. Every day shift every Mon, Thu for Weekly Showers/Skin Assessment. If answer is NO to shower - document the refusal or resident being OOP or appt. If answer is YES to the new skin alteration - document, it under the NUR Skin Assessment Form. Order date 3/17/2026.Minimum Data Set (MDS) assessment section C (cognitive pattern) scored R2 with brief interview for mental status (BIMS) score of 14, section gg (functional) of the same assessment documented that R2 requires maximal/substantial assistance from staff for all ADL care needs.Care plan initiated 3/18/2026 documented the following: monitor skin during care and report any changes, Offload bony areas using pillows, foam wedges, and/or offloading devices, Turn and reposition at least every 2 hours while in bed and as needed, reposition at least hourly while in wheelchair and as needed, etc.R3 is [AGE] years old and have resided at the facility since 2023, past medical history includes : Alzheimer's disease unspecified, encounter for attention to gastrostomy, adult failure to thrive, hypothyroidism, unspecified convulsion, malignant neoplasm of left kidney except renal pelvis, pressure ulcer of right elbow stage 3, pressure ulcer of sacral region stage 4, fall on same level from sipping, tripping and stumbling, essential primary hypertension etc.From 4/6/2026 to 4/8/2026 between 9:15AM and 2:38PM, R3 in bed lying on his back, floor mat x2, G-tube infusing, wound vac noted at bed side connected to resident, foley in privacy bag. R3 is scheduled to receive showers twice a week as documented in the following physician order: Weekly Showers/Skin Assessment. Acknowledgment of shower and skin assessment completed. If new skin issue: notify physician for order, notify family and complete NUR Skin Assessment Form, every day shift every Wed, Sat for Weekly Showers/Skin Assessment. If answer is NO to shower - document the refusal or resident being OOP or appt. If answer is YES to the new skin alteration - document it under the NUR Skin Assessment Form.Review of shower sheets for the past three months shows the following: In January 2026, R3 received 3 of the 9 scheduled showers. In February 2026 R3 received 3 of the 8 scheduled showers. In March 2026 R3 received 2 out of 5 scheduled showers. Additionally, 1 shower was given on a non-scheduled shower day. One shower was documented as being done on 3/25/2026, but R3 was hospitalized on that date. This observation was presented to V18 (LPN/Wound care) who stated that a shower would not have been possible since the resident was not at the facility. MDS assessment dated [DATE] coded R3 with a BIMs score of 3, indication memory problem, section gg (functional abilities) of the same assessment documented that R3 is dependent on staff for all ADL care needs, section h (bowel and bladder stated that R3 is frequently incontinent of bowel.R4 is 91 years and have resided at the facility since 2023, past medical history includes : Unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, chronic kidney disease unspecified, altered mental status, hypokalemia, dysphagia oral phase, muscle wasting and atrophy, not elsewhere classified, multiple sites difficulty in walking, gastrostomy status, unspecified osteoarthritis, hyperlipidemia, etc.R4 has the following active orders: Weekly Showers/Skin Assessment.Acknowledgment of shower and skin assessment completed. If new skin issue: notify physician for order, notify family and complete NUR Skin Assessment Form. every evening shifts every Tue, Fri for Weekly Showers/Skin Assessment. If answer is NO to shower - document the refusal or resident being OOP or appt. If answer is YES to the new skin alteration - document, it under the NUR Skin Assessment Form.Review of shower sheets for January, February and March for R4 showed that in January 2026 R4 received no showers or bed baths. In February 2026, R4 received 4 of the 8 scheduled showers. In March 2026 R4 received 2 of the 9 scheduled showers.MDS assessment dated [DATE] section C (cognition) was grayed out and did not indicate any BIMs score for R4, section gg (functional of the same assessment indicated that r4 is dependent on staff for all ADL care needs.R5 is [AGE] years old and have resided at the facility since 2023, past medical history includes: Dysphagia following cerebral infarction, encounter for attention to gastrostomy, presence of cardiac implants and grafts, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, hyperlipidemia, essential primary hypertension, Alzheimer's disease, peripheral vascular disease, non- pressure chronic ulcer of left heel, diabetes mellitus, etc.On 4/6/2026 at1:05PM, R5 was observed in bed lying on her back and could not respond to questions, floor mats x2, bed to the floor, G-tube feeding at bedside but not connected to R5. On 4/7/2026 at 11:27AM, Resident still in bed lying on her back, nonverbal but opens her to greeting, G-tube infusing at 75ml per hour.On 4/8/2026 at 8:43AM, Resident in bed lying on her back for the third day, awakes to greeting and shook her head yes when asked if she is doing okay. G- tube feeding and water flush bag dated 4/8/2026, pump on hold. At 8:45AM, observed wound care for R5 with V18 and V20 (LPN/wound Care), and observed a large area of maceration on resident's sacrum, area was cleaned with normal saline and new treatment applied by V18. R5 had an incontinence brief that was saturated with urine prior to wound care. Active physician order for R5 showed the following: Weekly Showers/Skin Assessment. Acknowledgment of shower and skin assessment completed. If new skin issue: notify physician for order, notify family and complete NUR Skin Assessment Form. Every evening shifts every Wed, Sat for Weekly Showers/Skin Assessment. If answer is NO to shower - document the refusal or resident being OOP or appt, if answer is YES to the new skin alteration - document it under the NUR Skin Assessment Form.Shower sheets for R5 for the months of January, February and March 2026 showed the following: In January 2026, R5 received 3 of the 9 scheduled showers. In February 2026 R5 received 6 of the 8 scheduled showers. In March 2026 R5 received 7 of the 8 scheduled showers.R6 is 82 years and has resided at the facility since 2023. Past medical history includes, but not limited to pressure ulcer of sacral region stage 4, hypertensive heart and chronic kidney disease with heart failure stage 1 through stage 4, chronic systolic (congestive) heart failure, encounter for attention to colostomy, anemia unspecified, major depressive disorder, retention of urine, etc.R6 has the following active order: Weekly Showers/Skin Assessment. Acknowledgment of shower and skin assessment completed. If new skin issue: notify physician for order, notify family and complete NUR Skin Assessment Form. Every evening shifts every Mon, Thu for Weekly Showers/Skin Assessment. If answer is NO to shower - document the refusal or resident being OOP or appt. If answer is YES to the new skin alteration - document, it under the NUR Skin Assessment Form.On 4/7/2026at 9:29 AM, surveyor interviewed R6 who said, I am in bed all of the time, they give me a bath in bed, but not too often.On 4/8/2026 at 8:40 AM, R6 stated that she went to get a shower once a long time ago. I get bed baths. My hair has not been combed in over a year. I've asked them to wash my hair, but they don't seem to have time. I can pay for a beautician to come in if they don't have time to wash my hair. I like to be clean.Review of shower sheets for R6 for the past three months showed the following: In January 2026, R6 received 3 of the 8 scheduled showers, additionally 2 showers were given on non-scheduled shower days. In February 2026, R6 received 3 of the 8 scheduled showers. In March 2026 R6 received 5 of the 9 scheduled showers.MDS assessment dated [DATE], section C (cognition) scored r6 with a BIMs score of 15, indicating that resident is cognitively intact, section gg (functional status) of the same assessment indicated that R6 is dependent/ substantial/maximal assistance from staff for most ADL care needs.On 4/7/2026 at 11:22 AM V18 (Wound Licensed Practical Nurse) stated that each resident receives a shower twice a week and as needed. On the shower days, the Certified Nursing Assistants (CNA) take the residents into the shower room. Upon disrobing of the resident, the CNA will pull the call light for the nurse to do a skin check on each resident before their shower. Once the nurse completes the skin check, the CNA completes the shower. For every shower, the CNAs complete a CNA Shower Sheet. V18 stated that if there is no shower sheet, that means that the shower was not given. The wound care tech files the CNA Shower Sheet in binders. When a resident does not receive a shower, a bed bath should be given, but that would be documented on the shower sheet with a handwritten note by the CNA that a bed bath was given instead of a shower. If a bed bath is given, the nurses would still have done a head-to-toe assessment. V18 stated that the nurses only document their head-to-toe skin assessment on the CNA Shower Sheet. It is not documented anywhere else. V18 added that if a resident does not get a shower or bed bath and doesn't get a head-to-skin assessment from the nurse, the risks include additional skin breakdown, new skin abnormalities, and the fact that the nurse does not get an overall look at the resident. There is also a risk of infection due to uncleanliness. Depending on the resident, it can be emotional. V18 stated that the overall care is poor if the resident is not getting a bath, shower or head to toe assessment. V18 stated that a bed bath is not as thorough as a shower.On 4/7/2026 at 11:22 AM V18 (Wound Licensed Practical Nurse) stated that CNA will call the nurse to do a skin check on each resident before their shower. If a bed bath is given, the nurses would still have done a head-to-toe assessment. V18 stated that the nurses only document their head-to-toe skin assessment on the CNA Shower Sheet. It is not documented anywhere else, if there is no shower sheet, then the shower is not done.On 4/8/2026 at 12:35 PM V26 (Certified Nursing Assistant/CNA) stated that the CNA shower Sheets are completed for every resident on their assigned shower day. Whether the resident has a shower, has a bed bath, or refuses; we will have a shower sheet for every resident on their assigned shower days. If we see a change in their skin, whether it is old or new, we will make sure that it is documented. We can document a change in the skin, or the nurse documents it, but the nurse does the assessment and signs off on the sheet. The nurse looks for any wounds or cuts or bruises or rashes, really any skin abnormality. If it is an old injury or change in the skin, it will still be on the shower sheet. The nurse is required to fill out the shower sheet. Sometimes the nurse does it before the shower or bath or sometimes after, but the nurse sees every resident. If the resident refuses a shower or bath, the nurse knows that too because the nurse is the last one to sign the sheet and we fill out a sheet for every resident. It is mandatory that we have a shower sheet for every resident on every shower day that they are scheduled. The shower sheet will either be filled out, or the shower sheet would say bed bath if the resident wanted a bed bath, or the shower sheet would say refused if the resident refused a bath or shower. It is a dignity issue.Surveyor requested for any documented skin assessments for R2-R6 but none was provided.Policy titled Bathing - Shower and Tub Bath revised 1/31/2018 stated in part that the purpose is to ensure resident's cleanliness to maintain proper hygiene and dignity. A shower, tub bath or bed/sponge bath will be ordered according to a resident's preference two times per week or according to the resident's preferred frequency and as needed or requested.

Based on observation interview and record review, the facility failed to provide services to promote wound healing by failing to obtain wound cultures as ordered for one (R3) of three residents reviewed for pressure ulcer. Findings include:R3 is [AGE] years old and has resided at the facility since 2023, past medical history includes: Alzheimer's disease unspecified, encounter for attention to gastrostomy, adult failure to thrive, hypothyroidism, unspecified convulsion, malignant neoplasm of left kidney except renal pelvis, pressure ulcer of right elbow stage 3, pressure ulcer of sacral region stage 4, fall on same level from sipping, tripping and stumbling, essential primary hypertension etc.MDS assessment dated [DATE] coded R3 with a BIMs score of 3, indicating severe cognitive impairment, section gg (functional abilities) of the same assessment documented that R3 is dependent on staff for all ADL care needs, section h (bowel and bladder) stated that R3 is frequently incontinent of bowel. From 4/6/2026 to 4/8/2026 between 9:15AM and 2:38PM, R3 in bed lying on his back, could not be interviewed due to cognitive decline.Hospital record dated 3/25/2026 documented principal/secondary diagnosis as necrotic sacral wound status post excisional debridement skin, soft tissue and muscle form necrotic sacral ulcer (18cm (centimeters) x16cm x 3.5cm depth) on 3/20/2026 by the surgeon. The same record continued in part: R3 is [AGE] year-old male with history of Alzheimer's dementia, hypothyroidism., who presented from nursing home due to concern for infected decubitus wound.CT abdomen pelvic: sacral decubitus ulcer extending to bone with locules of air tracking within soft tissues, surgery consulted and completed OR (Operating Room) debridement on 3/20/2026. ID (Infectious Disease) also consulted for antibiotics supported. Initial wound culture with Klebsiella pneumonia, Enterococcus faecalis, and Proteus mirabilis. R3 was treated with Zosyn for several days and discharged on Augmentin.On 4/7/2026 at 1:36PM, V20 (LPN-Licensed Practical Nurse/Treatment Nurse) said that R3 went to the hospital to follow up on a wound infection, resident was being followed by wound care three times a week and seen by the wound doctor once a week on Thursdays. The last picture of resident's wound was taken on 3/9/26. The measurements are: 12.00 x11.00 x2.80 (Length x Width x Depth-L x W x D) no infection was detected on the 16th but due to tissue changes, resident was sent out, he was already on antibiotics.Wound assessment detail report dated 3/2/2026 documented unstageable pressure ulcer measuring 13.00 x 14.00 x 2.80 (L x W x D) exudate - amount heavy, type serosanguineous.Wound detail assessment report dated 3/16/2026 documented the same wound with a measurement of 16.00 x 15.00 x 2.80 (L x W x D), same amount and type of exudate. Both assessments documented that resident was not on antibiotics.On 4/7/2026 at 3:49PM, V19 (Infectious Disease Nurse Practitioner) said that she is familiar with R3 and has been in his case since January. R3's wound was infected as indicated in January wound culture. R3 had a debridement recently, V19 ordered for a repeat wound culture but do not think it was collected. V19 said that the treatment resident was receiving was tailored to the result of the January wound culture, the wound showed improvement initially and then stopped. V19 said that R3 has been on an antibiotic, someone should have followed up on the wound culture order, the result could have given a different direction of treatment.Review of medical records showed wound culture dated January 16, 2026, that was positive for Klebsiella pneumonia and Enterococcus faecalis. R3 has three orders to obtain wound culture by V19 dated 2/7/2026, 2/18/2026 and 3/18/2026.Practitioner progress notes by V19, date of service 3/11/2026 documented in part: 2/18/26 ID for follow up on SSTI (Skin and Soft Tissue Infection). 2/14 labs revealed wbc (White Blood Cell Count)13.0, trending up. platelets 547, trending up. neutrophils 70.4, trending up. GFR (Glomerular Filtration Rate)102. CRP (C-reactive protein)16.82 ESR (Erythrocyte Sedimentation Rate) 126. Concern for worsening SSTI. Will start Ampicillin, Zyvox. wound cx (culture) reordered. 2/23 labs revealed wbc 12.3, platelets 705, neutrophils 63.8. ESR 127, CRP 16.9. Will continue to trend labs, awaiting wound culture, wound care following, recommendations appreciated.On 4/8/2026 at 3:15PM, V2 (DON-Director of Nursing) said that they do not have the results for wound cultures ordered for R3 on 2/7/2026 and 2/18/2026 because they were not completed. Resident was at the hospital on 3/18/2026 and that order was not completed. The purpose of the blood culture is to get appropriate antibiotics for resident's wound, the ordered culture should have been collected, it is not standard of practice not to follow physician's order. V2 spoke to the two nurses that received the orders, they do not have any reason why they did not carry out the orders. The expectation is for the order to be carried out and cannot give a definite reason why they confirmed the orders when they were not done.On 4/13/2026 at 10:03AM, V28 (Wound Doctor) said that he is not a fan of giving antibiotics to older people. When asked if the ordered wound culture for the resident should be collected and if it would have helped in the treatment, V28 said, ask the facility, they might have a reason why it was not collected, I don't think I ordered it.Physician orders entering and processing policy revised 1/31/2026 stated its purpose as to provide general guidelines when receiving, entering and confirming physician or prescriber's orders. (a prescriber is noted as physician, nurse practitioner, and a physician's assistant).Guidelines: 5. Following a physician visit, a licensed nurse will check for any orders that require confirmation under clinical> orders>pending orders. The orders will be confirmed by the nurse and the instructions for the order will be completed.Job description for registered nurse (RN) and licensed practical nurse (LPN) (undated) stated in part: The RN/LPN is responsible for providing direct nursing care to residents and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state and local standards, guidelines and regulations that govern our facility, and.to ensure that highest degree of quality care is always maintained.Essential duties and responsibilities:Complete and file required record keeping forms/charts upon resident's admission, transfer and /or discharge. Receive and transcribe telephone orders from physicians and record on the physician order form.

Based on interviews and record review, the facility failed to provide individualized fall interventions for one resident (R1) out of three residents reviewed for falls. R1 was assessed as a high risk for falls upon admission, fell out of bed twice in one week, was found to be unresponsive after the second fall, code blue was called, resident was revived and sent to local hospital for further management.Findings include:R1 is [AGE] years old admitted to the facility on [DATE], face sheet listed the following past medical history: chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, encounter to attention to tracheostomy, dependence on respirator/ventilator status, anorexic rain damage, encounter for attention to gastrostomy, anxiety disorder, etc.Fall assessment dated [DATE] documented a score of 71, indicating high risk for fall. Minimum data set (MDS) assessment dated [DATE] section C (cognition) did not have a brief interview for mental status (BIMS) score for R1, section gg (functional status) of the same assessment documented that R1 is dependent on staff for all activities of daily living (ADL) care needs, including rolling from left to right.Care plan initiated [DATE] for safety stated that R1 will be free of falls through the next review, interventions include providing hi-low bed, ensure in lowest position when resident in bed, sent to ER (Emergency Room), resident will be reviewed for appropriate intervention, upon return from hospital bilateral upper body wedges will be placed. Progress note dated [DATE] by V9 (LPN-Licensed Practical Nurse) documented in part: writer was summoned to room. resident was observed prone next to bed. bed was in lowest position. pt (patient) was assessed immediately. no injury, redness, or swelling noted. pt assisted back in bed via 4-person transfer. pt VS (vital signs) 173/99 p (pulse) 84 o2 (oxygen saturation) 98 trach/vent. Trach intact clean and patent. foley intact.Hospital record dated [DATE] documented in part: chief complaint gross hematuria. [AGE] year-old-male with past medical history ., presents to hospital for evaluation of gross hematuria. Nursing home reports patient sustained a fall at the facility yesterday and was found to have hematuria that began this morning.R1 was readmitted to the facility on [DATE] at 21:51 (9:51pm), at 22:19 (10:19), V9 (LPN) documented the following: 12:08am CNA summoned writer and respiratory therapist to the resident's room. pt was observed prone near bedside. Pt was assessed immediately. resident had no pulse, no rise and fall of the chest. code blue/CPR initiated at 12:15am. 911 was called at 12:16am 911 arrived at 12:26am. They took over code blue. family/ MD Notified.On [DATE] at 9:58AM, V9 (LPN) said that she is familiar with R1 and was present for his 2 fall incidents. The first fall occurred the day she came to work and shortly after rounding, about 12:00AM, resident was found prone on the floor by the CNA V9 assessed resident, he did not have any injuries, he was at the same baseline, vitals were stable V9 added that resident did not have any fall interventions except that his bed was at the lowest position and he had mittens, resident was slightly combative and moves a lot, but does not have any wedge or bolsters in his bed. On [DATE], V9 have just completed her rounds and started to gather supplies for the shift, the CNA was rounding at 12:00AM and found resident on the floor, CNA called V9 and the respiratory therapist and they went together to resident's room, his vent was disconnected, resident was unresponsive, code blue was called and the staff followed procedure.Hospital record dated [DATE] documented in part: Patient arrived from skilled nursing facility. Per EMS (Emergency Medical Services) patient had fallen from bed and a nurse thought patient was pulseless and initiated CPR for unknown amount of time. When EMS arrived, patient had stable vital signs and strong pulses. Patient remained with stable vital signs and with a pulse throughout transport. Physical exam documented Abrasion over left frontal scalp, CT of the head documented: No acute soft tissue abnormality. No skull fracture.On [DATE] at 11:30AM, V8 (R1's family member) said that R1 had a cardiac arrest in [DATE] and lost control of his body, his bed was kept low, but he did not have any bed rails or any other intervention to prevent him from falling, V8 requested for bed rail, bed bolster or any other assistive device to prevent R1 from falling out of bed but none was provided.On [DATE] at 1:43PM, V6 (respiratory Supervisor) said that he has worked at the facility for 2 years, is familiar with R1 and believes he was sent to the hospital because he fell out of bed, V6 is not aware of any injury. V6 cannot recall if R1 had any rails on his bed, he came back from the hospital on [DATE] and was sent out again on [DATE] around 12:08AM for another fall, V6 is not sure if resident has any bolsters on his bed but said that he had mats on the floor.On [DATE] at 3:42PM, V21 (CNA) said that she recalls R1 and was the assigned staff the day he had a fall, V21 said she changed R1 30mins before his fall, V21 was in another room when another CNA came to tell her that resident was on the floor, they called the nurse and they put resident back in bed using a sheet, the respiratory therapist was there too, V21 is not sure if resident is a fall risk, she did not get any report from previous staff, V21 is not sure if resident has any fall interventions.On [DATE] at 2:50PM, V2 (DON) said that he saw R1 after his first fall, he is a vent patient, staff reported that he was restless and moves to his left side, R1 fell and went to the hospital, he was not a candidate for bed rails, he came back from the hospital and fell again, R1 did not return to the facility, they could have worked on more interventions if resident came back.On [DATE] at 9:02AM, V27 (Respiratory Therapist) said that she recalls R1 and the day he had a fall, V27 did not witness the fall, was called by one of the nurses to help her in resident's room, when V27 got to the room R1 was face down on the floor, he was put back in bed, his vent was not disconnected, resident did not have any injuries upon assessment. V27 does not think resident has any rails on his bed, did not have any bolsters that she can recall, resident tossed around a lot, his bed was kept low.On [DATE] at 10:44AM, V29 (respiratory therapist) said that the day R1 had a fall, she was in the therapy room charting when someone came to get her, they went to resident's room and she saw R1 on the floor, his vent was disconnected and it was beeping, V29 said she is not sure she heard the beeping from the respiratory room but the sound is usually loud, V29 is not sure how long R1 was disconnected, she was unable to get a pulse or saturation, they called a code and started CPR, 911 was called, they arrived and took over CPR. V29 does not recall if resident had any injuries, or if he had any rails or bolster in his bed, not sure if resident was a fall risk, his bed was low and he had mittens on his hands, V29 does not recall any other fall interventions for R1.Fall prevention policy revised [DATE] stated its purpose as to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality assurance programs will monitor the program to ensure ongoing effectiveness.Standards: A fall risk assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical guidelines.Safety interventions will be implemented for each resident identified at risk

Based on observation, interview, and record review, the facility failed to follow their Weight Assessment and Interventions Policy and Unintentional Weight Loss Policy. Specifically, the facility did not report poor appetite and decreased oral intake to the physician and dietician and failed to develop interventions to prevent further weight loss. Additionally, the facility failed to ensure that one resident who was identified as at risk for malnutrition and dependent on enteral nutrition, received his enteral feeding as ordered. The facility also failed to implement dietician recommendations and to evaluate interventions to promote weight gain. This affected three of three residents reviewed for prevention of weight loss and nutrition (R34, R46, and R9) These failures resulted in R34 experiencing severe weight loss of 9.1% over 9 days, R46 experiencing severe weight loss of 11.5% over one month, and R9 experiencing an unplanned weight loss of 20 pounds over approximately 10 months. Findings include:1. R9 was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure, anoxic brain damage, cardiac arrest, convulsions, type II diabetes, dysphagia, gastronomy and anemia. R9's admitting weight dated 4/30/25 documents 118 pounds. R9's weight summary documents: body max index 15.4 goal weight range 158-191 pounds. According to the Centers for Disease control a body max index of 15.4 is underweight. On 2/6/26 at 9:26AM, R9's weight taken by V9 (Restorative aide) and V11 (Restorative aide) via mechanical lift. Weight scaled displayed zero prior to weight being taken. Weight measured at 98.6 pounds. On 2/5/26 at 4:35PM, R9 was observed in bed. R9's artificial feeding was hung dated 2/4/26 with pump on but not infusing. Pump displayed pump inactive pump has been idle for 10 minutes. On 2/6/26 at 8:46AM, R9 was observed in bed. R9's artificial feeding was hung dated 2/4/26 with pump on but not infusing. Pump displayed pump inactive pump has been idle for 10 minutes. On 2/6/26 at 9:26AM, R9's feeding pump displayed inactive pump has been idle for 10 minutes upon entering room with staff for weight observation. On 2/6/26/at 9:54AM, V3 (Nurse) was observed in R9's room. V3 said she was turning off R9's feeding because it is due to be turned off at 10:00am. V3 was asked to verify the amount of feeding administrated. Pump read 38 ml given that hour. V3 unsure why it only displayed 38ML. V3 said she does not need to do anything with the feeding but just needs to stop the feeding at 10:00AM. V3 turned off the feeding and left the room. On 2/6/26 at 11:27AM, V2 (Director of nursing, DON) showed surveyor a new bottle of artificial feeding 1.5 which contained 1000 milliliters (ML). V2 (DON) was asked to confirm the feeding bottle and feeding amount in R9's room. V2 confirmed that there was one bottle of jevity 1.5 hanging in the room dated 2/6/26 with about 800ml left in the bottle with no time documented. V2 said the overnight shift would have hung a new bottle on their shift the feeding was currently off due to the order stating to stop at 10:00AM. V2 said nursing staff are expected to ensure the full amount of feeding was provided to the resident prior to stopping the feeding at 10:00AM. It is expected that the nurse would check the feeding pump to ensure the full amount was given and if not that the feeding would continue until the full amount was given. Pump displayed total feed for the hour was 38ML and total daily was 774ML and water flushed was 750ML. R9's physician order sheet dated documents: two times a day Jevity 1.5 @ 80 ml/hour x 20 hours/day - Total 1600 ml daily off 10 am on 2 pm. On 2/26/26 at 2:55PM, V13 (Dietician) said she would expect staff to be following the feeding orders and should continue the feeding until the resident has reached the total amount given. V13 said the resident not receiving all the required feeding can lead to weight loss, dehydration and potentially worsening of pressure sores. On 2/6/26 at 4:27PM, V18 (Medical Doctor/MD) said he would expect R9's feeding to be given as ordered and that the total amount of feeding would be given. R9's mini nutritional note dated 1/16/2026: R9 admitted on [DATE]. No hospital stays this quarter. At risk of malnutrition due to body max index (BMI). No edema or Gastrointestinal distress documented: Height: 68 inches weight: 101# (45.9 kg) BMI: 15.4 (underweight). Gradual, intentional weight gain is desirable. Per weight history, no clinically significant weight changes x 1, 3, or 6 months. Diet: NPO (nothing by mouth). NKFA (no known food allergies). Liquid protein 30 ml BID (twice daily). Estimated nutritional needs: 1606-1836 kcals (35-40 kcal/kg) 69- 92 g protein (1.5-2.0 g/kg) 1606-1836 ml fluid (1ml/kcal)TF (tube feeding): two times a day Jevity 1.5 @ 80 ml/hour x 20 hrs/day - Total 1600 ml daily off 10 am on 2 pmFWF (free water flush): every shift Flush GT (gastrostomy tube) with 250 ml of water Q4H (every 4 hours) via pumpTF provides: 1600 ml total volume, 2400 kcals, 102 g protein, and 2716 ml total fluid (free water + flushes). Percent of estimated nutritional needs met: 131% kcals, 111% protein and 148% fluid.Recommendations: current TF order meets/exceeds estimated nutritional needs for healthy weight and wound healing. Add multivitamin (MVI/MIN) and Vitamin C for wound healing. R9's physician order sheet dated 2/6/26 does not document any orders for multivitamin (MVI/MIN) and Vitamin C. R9's medication administration record for January 2026 and February 2026 do not document any orders for multivitamin (MVI/MIN) and Vitamin C. On 2/6/26 at 4:27PM, V18 (MD) said he would expect dietician recommendations to be followed. R9's weights document: 5/29/25 119 pounds; 6/6/25 120 pounds; 7/9/25 103 pounds, 7/28/25 105 pounds, 8/4/25 104 pounds, 9/9/25 100 pounds, 10/3/25 101 pounds, 11/4/25 100.5 pounds; 12/8/25 103 pounds, 1/5/26 101 pounds. No weight recorded for February. R9's dietician notes 12/15/25 documents: Gradual, intentional weight gain is desirable. Per weight history, weight loss of -14.9% , -18 Lb x 6 months. No clinically significant weight changes x 1 or 3 months. TF provides: 1600 ml total volume, 2400 kcals, 102 g protein, and 2716 ml total fluid (free water + flushes).% of estimated nutritional needs met: 128% kcals, 109% protein and 145% proteinRecommendations: continue present management. R9's dietician notes 11/17/25 documents: Weight stability or gradual, intentional weight gain is desirable. Per weight history, unplanned weight loss of -8.0% , -8.7 pounds x 3 months and -15.1% , -18 pounds x 6 months. Weight stable x 1 month. TF provides: 1600 ml total volume, 2400 kcals, 102 g protein, and 2716 ml total fluid (free water + flushes).% of estimated nutritional needs met: 131% kcals, 112% protein and 149% fluid. Recommendations: Current TF/FWF meet/exceed estimated nutritional needs to support healthy weight and wound healing R9's dietician notes 10/14/25 documents: He is NPO and receives via G-tube Jevity 1.5 @ 80ml/hr x 20hrs with 250ml FWF q 4hrs. This provides 2400 kcals, 102 g protein, and 2716 ml total Weight (10/3) 101#, BMI of 15.4 is within underweight range. This provides 2400 kcals, 102 g protein, and 2716 ml total fluid (free water + flushes). No significant weight changes x 1 or 3 months. Gradual weight loss is desired for resident r/t (related to) malnutrition. Current feeding volume is adequate to meet 100% of kcal, 100% protein, and 111% fluid estimated needs. Continue present management. R9's dietician notes 9/15/25 document: TF: Jevity 1.5 @ 80mL/hr x 20hrs (ON 2pm; Off 10am) or until 1600mL total volume formula has infused w/ 250mL flushes q4h. TF formula was changed from Jevity 1.2 to Jevity 1.5 on 9/2 to support wt gain and wound healing. TF and flushes provide 2400kcal, 102g protein and 2716mL total fluid (1216mL via TF+ 1500mL flushes). This supports 100% kcal, 100% protein and 111% fluid estimated nutritional needs. No GI distress or TF intolerance noted. BMI of 15.5- underweight. Wt hx shows significant 7.4#(6.8%) wt loss x 1 month and significant 19#(15.7%) wt loss x 3 months. Wt loss likely r/t Dx, wounds, fluid shifts and possible SE of Rx. Wt stability or intentional, gradual wt gain is desired. Estimated needs based on IBW for wt gain (70kg): 2100-2450kcal @ 30-35kcal/kg, 84-105g pro @ 1.2-1.5g/kg and 2100-2450mL @ 1.0mL/kcal. Refer RD as needed. Continue present management. R9's dietician notes 7/21/25 document: R9's weight: 103# (46.8 kg) 7/21 wt. ht: 68 inches BMI: 15.7 (Underweight). Weight stability or gradual, intentional weight gain is desirable. Per wt hx, weight loss of -14.9% , -18 Lbs x 1 month and 12.7% , -15.0 pounds x 3 months. Last amount of weight lost in a short period of time, will monitor weekly weights. Recommendations: Weekly weights x 4 weeks. Increase TF to 80 ml/hr x 20 hours. TF will provide: 1600 ml total volume, 2400 kcals, 103 g protein and 1216 ml free water. R9's dietician notes 6/19/25 document: Current wt: 120.8# (54.9 kg) ht: 68 inches BMI: 18.4 (underweight). Weight stability or gradual, intentional weight gain is desirable. Recommendations: Change TF to meet new facility guidelines. Jevity 1.5 @ 70 ml/hr x 20 H, ON at 2PM and OFF at 10 AM. Total volume 1400 ml. FWF per MD. TF will provide: 1400 ml total volume, 2100 kcals, 89 g protein, 1064 ml free water. On 2/6/26 at 5:00PM, V2 (DON) was asked what interventions the facility put in place following R9's weight loss to promote weight gain or healthy weight for R9. V2 said the facility adjusted R9's feeding in July by increasing the rate of the feeding from 70 ml to 80 ml an hour. V2 said they changed the type of artificial feeding as well from jevity 1.2 to jevity 1.5 for more calories. On 2/6/26 at 2:55PM, V13 (Dietician) said residents receiving tube feeding are seen monthly to monitor. R9 had weight loss from June to July. V13 said they increased the feeding from 70 ml an hour to 80 ml an hour and implemented weekly weights. V13 said she is unsure what caused the weight loss or if there was anything additional done to evaluate R9's weight loss. V 13 said R9 was receiving enough caloric and nutritional needs that would maintain weight. On 2/6/26 at 4:27PM, V18 (MD) said he is aware of R9's weight loss and said it could be possibly due to an absorption issue. V18 was asked how you confirm that it is an absorption issue, and not an underlying condition, or not providing the feeding as ordered. V18 said R9 would need to have further testing to confirm an absorption issue that would require a hospital stay. V18 said that there is no acute reason that R9 would require hospitalization and that if the facility sent R9 to the Emergency room, they would probably send him right back. V18 said R9 does not have any diagnosis or conditions that would attribute to the sudden weight loss. V18 said R9 has not had any acute infections that would have caused weight loss. V18 said R9 has been stable but due to his wounds and tracheostomy status, he has a poor quality of life and would be appropriate for hospice. R9's artificial feeding order history documents: 4/30/25 – 6/19/25 jevity 1.2 at 65ml an hour x 21 hours total 1365 ml daily; 6/21/25- 7/21/25 Jevity 1.5 @70 ml/hour x 20 hours/day - Total 1400 ml daily; 7/21/25 Jevity 1.5 @80 ml/hour x 20 hrs/day - Total 1600 ml daily. There were no other increases to the feeding documented. R9's care plan dated 5/2/25 documents: R9 requires enteral feedings as the primary source of nutrition that puts resident at risk for: Aspiration, Malnutrition, Dehydration, and Intolerance. Enteral feeding is related to: Dysphagia. Interventions: Diet: nothing by mouth (NPO); Elevate head of bed to prevent aspiration. Date Initiated: 05/02/2025; Enteral nutrition per physician order. Date Initiated: 05/02/2025; Monitor for complications including aspiration, diarrhea, respiratory infection, dehydration, abdominal pain, feeding tube displacement, nausea, vomiting, and abnormal lab values. Notify nurse or physician as indicated. Date Initiated: 05/02/2025; Monitor weights: Monthly per routine. Date Initiated: 05/02/2025. R9's mini nutritional assessment dated [DATE] documents malnourished; mini nutritional assessment dated [DATE] documents malnourished; mini nutritional assessment dated [DATE] documents malnourished; mini nutritional assessment dated [DATE] documents at risk for malnutrition. Facility policy titled Enteral Nutrition- tube feeding dated 2020 documents: Nursing staff will follow community enteral nutrition policies and guidelines. Monitoring of the residents actual intake and tolerance of tube feeding is important to ensure that nutritional goals are met and maintained. monitoring of the resident with a tube feeding is an interdisciplinary team effort and includes: enteral feeding delivered as ordered by physician; weights. Facility policy titled Unintentional Weight Loss dated 2020 documents: Unintentional weight loss can have serious implications for older adults. Studies indicate unintentional weight loss can lead to malnutrition, poor wound healing, risk of pressure sores, decline in function and inability to fight infections. Unintentional weight loss can be rapid or sometimes slow an insidious. Its important that systems are in place to detect, assess and develop individualized plan of care for residents with weight loss. For individuals with unintentional weight loss. Monitoring is vital after plan of care implementation to assess progress on nutritional related goals. Goals may need to be modified and new interventions implemented based individual responses to current interventions, their weight and other factors related to their medical conditions. 2. On 2/6/26 at 9:30 AM, V7 (restorative director) stated that all newly admitted and re-admitted residents will have weights done weekly x 4 weeks. V7 stated that if the resident has +/- 5 pound weight change from previous weight, the restorative aides will automatically re-weigh the resident to verify the accuracy of the weight obtained. V7 stated that the re-weight is done immediately and only the re-weight is entered into the resident's electronic medical record. V7 stated that if there is a change in the resident's weight will be reviewed by V13 RD (registered dietitian). V7 stated that the facility has a NARs (nutrition at risk) meeting weekly that V13 attends and any nutritional concerns are discussed. The resident's nurse is responsible for notifying the physician of any weight loss. V7 stated that R34's weight on 2/1/26 was 179.5 pounds. On 2/6/26 at 2:48 PM, V13 RD stated that she has up to one month to evaluate residents' who have experienced changes in weight +/- 5 pounds. V13 stated that she was not notified of R34's 18-pound (9.1%) weight loss from 12/27 – 1/5. V13 stated that the nurse should have notified her of R34's weight loss on 1/5. V13 stated that weight fluctuations will be seen in residents with diagnosis of CHF (congestive heart failure). V13 reviewed R34's medications and stated that while R34 has a diagnosis of CHF he is not receiving any diuretic medication that could explain his weight loss. V13's RD note, dated 1/30/26, notes R34's current weight is 180.5 pounds on 1/5. Weight stability is desirable but anticipate weight fluctuating with diagnosis of CHF and fluid shifts. Per weight history, weight loss of 18 pounds, 9.1% x about 1 week, add weekly weight to monitor weight trends. Skin is intact, with no active wounds per wound rounds. R34 is on a no added salt diet, mechanical soft texture, thin consistency. Oral intakes of meals per POC (point of care) documentation are good, consuming >51% of most meals. No reported issues chewing/swallowing current diet order. Recommendations: Weekly weight x 4 weeks to monitor weight trends. There is no documentation found in R34's medical record noting the physician or the registered dietitian was notified of R34's weight loss on 1/5/26. There is no documentation noting any interventions were implemented between 1/5 and 1/30 for weekly weight monitoring or the addition of nutrition supplements in R34's medical record. R34's weight documentation notes: R34's weight on 12/20/25 was 195.5 pounds; on 12/27/25 it was 198.5 pounds; and on 1/5/26 it was 180.5 pounds. R34's POS (physician order sheet), dated 1/5/26 – 2/6/26, does not note any orders for weekly weights or for nutritional supplements to prevent further weight loss. R34's medical record does not note weekly weights x 4 weeks were obtained on re-admission to the facility on [DATE]. The nurse practitioner's note, dated 1/7/26, nor the physician's note, dated 1/20/26, note R34's weights were reviewed. 3. On 2/6/26 at 2:48 PM V13 RD stated that she was not made aware of any further weight loss for R46. V13 stated that R46's weight loss was 9.9 pounds (3.72%) from 12/17 – 1/5, which is not significant. V13 stated that gradual intentional weight loss would be 1–2-pound weight loss per week. V13 stated that weight fluctuations will be seen in residents on dialysis and those with diagnosis of CHF (congestive heart failure). V13 reviewed R46's medications and stated that while R46 has a diagnosis of CHF she is not receiving any diuretic medication that could explain their weight loss. V13 stated that she will monitor R46's weights because of the downward trend. On 2/6/26 at 3:05 PM, V23 (dialysis staff) presented R46's dialysis communication report for today. R46's post dialysis weight is noted to be 102.6 kg (kilograms) which is 226.2 pounds. R46 has had an 11.5% weight loss in one month, 1/5 to 2/6. R46's medical record notes on 1/23 R46's post dialysis weight was 109.8 kg or 242.1 pounds. On 1/28 R46's post weight was 107.4 kg or 236.8 pounds. R46's pre-weight documentation on all dialysis communication reports, dated 1/7 through 2/6, is noted to be 255.6 pounds. R46's amount eaten documentation for the past 30 days was reviewed. There was documentation found for 80 out of 90 meal opportunities. R46 consumed 0-25% of meals on 4 occasions; 26-50% on 13 occasions; 51-75% on 13 occasions; 76-100% on 46 occasions; and refused meals on 4 occasions. V13's RD note, dated 1/9/26, notes R46 was admitted on [DATE]. Current weight is 255.6 pounds on 1/5. Body mass index is 46.7 (obese). Gradual, intentional weight loss is desirable, but anticipate weight to fluctuate with fluid shifts. No clinically significant weight changes since admission. Skin is intact, no active wounds per wound rounds. No edema or GI distress documented. R46 is on a consistent carbohydrate/LCS (low concentrated sweets) diet, regular texture, thin consistency (milk with every meal). Nepro (supplement) 60 ml (milliliters) daily. Oral intakes vary per POC documentation, 0-100% of meals x 1 month. No reported issues chewing/swallowing with current diet order. Recommendations: continue present management. The facility's weight assessment and intervention policy, dated 2020, notes any weight change of 5% or more since the previous weight assessment shall be re-taken the next day to confirm. If the weight is verified, nursing will notify the appropriate designated individuals such as physician, registered dietitian, or other members of the interdisciplinary team within 24 hours. Verbal notification must be confirmed in writing. The registered dietitian will review the weight log each month to follow individual weight trends. The threshold for significant weight loss shall be based on the following criteria: one month – significant weight loss of 5%, severe loss > 5%; three months – significant weight loss of 7.5%, severe loss > 7.5%; and six months – significant weight loss of 10%severe loss > 10%.

Based on observations, interviews, and record reviews, the facility failed to follow its Pain Management Policy. The facility did not assess a resident with new-onset pain, failed to document the new-onset pain, and did not ensure the resident's physician was notified or obtain an order for pain medication for one resident (R17) out of three reviewed for pain management in a sample of 44. As a result, R17 experienced psychosocial harm, enduring excruciating pain for more than 20 hours without pain medication. R17 self-reported a pain rating of 12-13 on a 1-to-10 scale. Findings include:On 2/4/26 at 1:00 PM, this surveyor observed R17 to be alert and oriented x 3. R17 stated that he was in pain. R17 stated that he has wounds on both heels. When asked to rate his pain on a scale of 1 to 10, R17 responded 12-13. When asked if R17 notified the nurse of his pain, R17 stated that staff think he is senile and don't do anything when he complains of pain to them. R17 appears to be restless, frustrated, his face is saddened/pained when speaking with this surveyor. R17 stated that he takes naproxen at home; it takes the edge off his pain, and he is able to function.On 2/4/26 at 1:05 PM, this surveyor made V3 (nurse) aware of R17's complaint of pain, 12-13 out of 10. V3 stated that V3 would address his pain right away. V3 checked R17's medication record. V3 stated that R17 did not have any medication ordered for pain and V3 would call R17's physician to obtain an order.There is no documentation found in R17's medical record noting R17's physician was notified on 2/4 for an order for pain medication.On 2/5/26 at 10:30 AM, R17 stated that he did not receive any medication for the pain the day before. When asked to rate his pain on a scale of 1 to 10, R17 responded 12-13. R17 appears even more restless, frustrated, his face is saddened/pained when speaking with this surveyor.On 2/5/26 at 10:30 AM, V4 (nurse) was informed of R17's complaint of pain. V4 immediately checked R17's medication record and stated that R17 does not have an order for pain medication, and she will call the physician right away to obtain orders.On 2/6/26 at 12:45 PM, R17 was observed to be calm, smiling, and relaxed. R17 stated that he received medication for pain, and he feels much better.R17's POS (physician order sheet), dated 2/5/26 at 10:40 AM, notes an order for naproxen sodium 220mg (milligrams) oral for pain.R17's MAR (medication administration record), dated February 2026, notes V4 administered naproxen tablet on 2/5 at 10:45 AM and on 2/6 at 8:39 AM.R17's care plan, initiated 1/8/26, notes R17 has potential for pain. Interventions include but not limited to administer analgesia as per orders, monitor R17's complaints of pain or requests for pain treatment and notify nurse, monitor signs and/or symptoms of non-verbal pain: vocalizations (silence), mood/behavior (changes, restless, squirmy), eyes, face (sad), body. Notify physician of any complaints of pain.R17's care plan, initiated 1/12/26, notes R17 has arterial wounds on the left and right heels related to peripheral artery disease. Interventions include but not limited to pain management and assess for pain and administer pain medications as ordered, observe feedback and notify physician as necessary.The facility's pain management policy, revised 7/6/18, notes in part, when the resident is unable to describe pain, physical signs such as grimacing, body posturing, vital signs, and changes in behavior and mood will be used to determine the presence of pain.

Based on observation, interview and record review, the facility failed to follow the physician order and ensure the low air loss mattress was in place for a resident identified with a pressure sore. This affects one of three residents (R3) reviewed for pressure prevention interventions in place in the sample of 44. On 2/4/26 at 1:20pm R3 was observed resting in bed in supine position, V25 (Certified Nurses Assistant/CNA) was assisting R3 with his meal. R3 was observed resting on a regular mattress. V25 verified that R3 was not resting on a low air loss mattress. There was not a pump for the air mattress noted. V25 said R3 has a pressure sore to the perineal area and buttocks.R3's plan of care for pressure injury to coccyx with initiated date of 12/21/2025 denotes in-part for interventions low air loss mattress in place with appropriate settings and functioning properly date initiated 12/31/25.Review of R3 physician order sheet with order date 12/31/25, shows low air loss mattress in use. Check for proper functioning and settings, every shift.R3's wound assessment completed by the physician denotes in-part wound (sacral), wound two (perineal/scrotal), wound three scrotal- exudate is moderate. Prevention protocols: use appropriate mattress based on wound stage.On 2/5/26 at 12:00pm V16 (Wound Care Coordinator) said R3 was placed on the low air loss mattress today 2/5/26. R3's physician orders for low air loss mattress dated 12/31/25 were reviewed with V16. V16 said the low air loss mattress should have been implemented when the physician ordered it on 12/31/25. V16 said R3's wound treatments are completed by the wound Nurse, and the wound Nurse should have recognized that R3 did not have a low air loss mattress in place. V16 said no one informed her that R3's mattress was not in place as per ordered. V16 said the air mattress was supplied by the facility, and the mattress did not need to be ordered. V16 said R3 has a stage two pressure sore and a low air loss mattress is appropriate for a stage two pressure sore. V16 said not having the air mattress in place increases R3's risk for skin breakdown, the low air loss mattress helps to reduce pressure, promote circulation, and promotes wound healing.Facility comprehensive care plan policy dated 11/28/12 denotes in-part to develop a comprehensive care plan that directs the care team and incorporates the residents' goals, preference and services that are to be furnished to attain or maintain the residents' highest practicable, physical, mental and psychosocial well-being. The facility will develop and implement A comprehensive person-centered care plan for each resident consistent with the residents' rights that includes measurable objectives and time frames to meet a residence medical nursing and mental and psychosocial needs that are identified in the comprehensive assessment.Facility wound management program policy denotes in-part, the purpose of our wound management program a is to ensure our residents have access to the appropriate assessment and management in the prevention and treatment of pressure injuries and other wounds in accordance with clinically accepted guidelines to improve quality of life for all residents in our care and to improve resident outcome and maximize health status and quality of life by using evidence based wound care principles through a cost effective standardized process.

Based on observation, interview and record review the facility failed to ensure that the call light was within reach for one of eight dependent resident (R129) reviewed for accommodation of needs in sample of 44. On 2/4/26 at 12:58pm R129 was observed sitting at the bedside, R129 awake able to answer yes and no questions, R129 also communicates using gestures. When asked if R129 had his call light, R129 looked left and right and said no. R129 call light was observed wrapped around the headboard. Before leaving the room R129 gestured for surveyor to turn off room light. At 1:22pm R129's call light remained wrapped around the headboard. On 2/5/26 R129 observed laying in bed, R129 said he does not have his call light.2/5/26 at 10:56am V9 (Restorative aide) summoned to the room to locate R129's call light, V9 was observed to lift R129 mattress up and remove the call light from under the mattress and place it next to R129. V9 said R129's call light should be within reach. The call light is for R129 to call for help or in case of an emergency.Facility call light policy dated 12/28/12 denotes to respond to residents' requests and needs in a timely and courteous manner, resident call light should be answered in a timely manner. All residents that have the ability to use a call light: have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location.

Based on interviews and record reviews, the facility failed to ensure a Level II PASARR (preadmission screening and resident review) evaluation was completed for one resident with a diagnosis of mental disorder during the stay. This affects one of three residents (R113) reviewed for PASARR's in a sample of 44. Findings include:On 2/6/26 at 3:45 PM, V14 (social services director) stated that a PASARR II should be requested for a resident as soon as an SMI (severe mental illness) diagnosis is made known. V14 stated that social services requested a PASARR II today for R113 when the need for a level II was identified.R113's PASARR I, dated 9/30/25, notes R113 with a mental health diagnosis of anxiety disorder. No evidence of a PASARR condition of a SMI, if changes occur or new information refutes these findings, a new screen must be submitted.R113's medical record notes R113 was admitted to this facility on 10/4/25. On 10/8/25, R113 was diagnosed with bipolar disorder.There is no documentation in R113's medical record noting a PASARR II was requested prior to 2/6/26.

Based on interviews and record reviews, the facility failed to update a resident's nutrition care plan within seven days of his comprehensive assessment that noted significant weight loss in one month. This failure affected one resident (R34) out of three residents reviewed for care plan revision in a sample of 44. Findings include: On 2/6/26 at 2:48 PM, V13 RD (registered dietitian) stated that V13 saw R34 on 1/30/26 and updated R34's care plan to address his weight loss and implement new interventions. R34's weight documentation notes on 12/20/25, R34's re-admission weight was 195.5 pounds. On 12/27, R34's weight was 198.5 pounds. On 1/5/26, R34's weight was 180.5 pounds. R34's re-admission comprehensive assessment, dated 1/7/26, notes R34 with weight loss of 5% or more in the last month. It also notes R34 is not on a weight loss regimen. R34's care plan, dated 1/30/26, notes R34 has experienced weight loss and is at risk for continued weight changes. Weight stability is desirable but anticipate weight to fluctuate due to diagnosis of congestive heart failure. R34 with weight loss of 18 pounds, 9.1% in about one week.

Based on interview and record review, the facility failed to follow the medication administration policy and physician orders to ensure residents receive their prescribed medication. This affects one of three residents (R13) reviewed for medication administration in a total sample size of 44. Findings Include:On 2/5/26 at 3:00pm, V15 (Family of R3) said, R13 missed his chemotherapy medication in January after she gave it to V8 (Assistant Director of Nursing/ADON). On 2/7/26 at 9:55am, V2 (Director of Nursing/DON) said, R13's medication was not given because V8 (ADON) had R13's medication on her desk which was inaccessible to the floor nurse at the time of administration. V2 said, he expects the nurse to follow doctor's orders and give medication as prescribed. On 2/7/26 at 10:04am, V15 said, she brings R13's medication to the facility from the veteran's hospital to ensure he does not have a lapse in care. V15 said, R13 gets two darolutamide pills twice a day. V15 said, she received a call from the facility on 1/28/26 reporting that R13 only had one pill left. V15 said, she explained to that nurse she left the new bottle of medication with V8, and it would have been enough for R13 to have his medication on 1/28/26. Medication administrator record dated 1/28/26 document: darolutamide oral, NA- not available.Progress note dated 1/28/26 created on 2/5/26 (during the survey) documents: late entry Resident (R13) received Darolutamide. Nurse Practitioner and V15 made aware. Physicians Orders-Entering and Processing dated 1/31/18 did not apply.

Based on observation, interview and record review, the facility failed to follow their medication storage policy by not documenting the open date on two open bottles of tuberculin solution for two of two bottles reviewed for medication storage.Findings include:On 2/4/26 at 3:30PM, observations conducted in the first-floor medication room with V3 (Nurse). There were two bottles of facility house stock tuberculin solution stored in the refrigerator. Both bottles were open (no safety seal on top of the bottle) within their original packaging box. V3 was unable to find open dates on the bottle or box for both tuberculin solutions.On 2/4/26 at 3:33PM, V2 (DON-Director of Nursing) confirmed that the two bottles of tuberculin did not have any dates on the box or bottles. V2 said the bottles of tuberculin should be dated when opened.Facility medication storage policy revised 7/2/19 documents: to ensure proper storage, labeling and expiration dates of medications biologicals, syringes and needles. Under general storage procedures documents: Once any medication or biological package is opened, facility should follow manufacturer guidelines with respect to expiration dates for opened medication. Facility staff should record the date opened on the medication container when the medications has a shortened expiration date once opened.According to the food and drug administration,A vial of Tubersol (tuberculin solution) which has been entered and in use for 30 days should be discarded.

Based on record review and interviews the facility failed to provide a resident's medical record to the Power of Attorney (POA)/Healthcare Representative (HCR) in a timely manner after a request was made, for 1 (R11) of 1 resident reviewed for medical records request.Findings include:On 1/22/2026 at 10:50am V5 (Medical Records) stated, I did receive a request in October 2025 from R11's POA. The POA completed an application and submitted Identification. I did need some more documents, and I was unable to reach the POA to inform them of the needed documents. I should have mailed out a certified letter and did not, moving forward I will be sending a certified letter if I'm unable to contact family by phone.On 1/22/2026 at 11:40am V1 (Administrator) said that V5 should have sent a certified letter to the POA for needed documents and moving forward that is the plan.An admission record dated 1/20/2026 indicates R11 had a diagnosis of chronic ischemic heart disease, heart failure renal dialysis, pressure ulcers, a state of Illinois compliant authorization for release of patient information dated 10/1/2025, a request for information on 1/20/2026.Facility Policy: Medical Record PolicyPurpose: To ensure that a complete accurate and legal record the resident's care maintained contains justification of diagnoses, treatment results. The record is readily accessible systematically organized to provide a medium of communication among health care professionals involved in the resident's care and to facilitate retrieval and compilation of information.Responsibility: Administrators, Directors of Nursing, Medical records technician.Policy: It is the policy of this facility that an organized, accurate and complete written record will be maintained for each resident in accordance with applicable state and federal guidelines and laws.Standards:The director of nursing/designee with the support of the medical records technician shall assure that medical records are maintained in accordance with the facility/s policies and procedures, and applicable federal and state regulations.

Based on observation, interview, and record review the facility failed to ensure ongoing revision and updated the resident individualized care plan according to the resident's condition and treatments. This deficiency affects two (R5 and R6) of three residents reviewed for Care plan revision.Findings include:R6 was admitted on [DATE], with diagnoses listed in part but not limited to Alzheimer's disease, Dementia, adult failure to thrive, type 2 diabetes mellitus, chronic ischemic heart disease.Physician active orders: no order for oxygen use.On 1/21/26 at 10:25AM, R6 observed in room laying down, with oxygen in use, at 2L (liters) per nasal cannula, tubing with no label date. On 1/21/26 at 10:44AM, V2 (Director of Nursing) made aware of above findings and said that the oxygen should have a physician's order for administration and tubing should be labeled with date.On 1/21/26 at 1:30PM, V1 (Administrator) made aware of R6 with oxygen in use and no physician order or label on tubing with date, and no care plan for oxygen in use. R5 is a [AGE] year-old with the following diagnosis :chronic respiratory failure with hypoxia, encounter for attention to tracheostomy, dependence on respiratory ventilator status, encounter for attention to gastrostomy, displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, essential hypertension, other seizures, anxiety disorder, adjustment disorder with depressed mood, major depressive disorder, generalized edema, pain in left hip, diaphragmatic hernia without obstruction or gangrene, delirium due to known physiological condition.R5 Fall Risk scale dated 10/26/25 indicates High risk for falling.The Care Plan dated 2/27/25 documents R5 is at high risk for falls gait/balance problems, poor communication/comprehension, decreased safety awareness, and adverse behaviors: interventions in place include 2/27/25-keep furniture in locked position,6/20/25 -educate resident to use call light for assistance with toileting and ADL's (Activities of Daily Living), 10/21/25- Bilateral floor mats. 11/29/25-no intervention, 12/1/25-no intervention.On 1/21/26 at 2:00PM, V2 (Director of Nursing) said R5's fall care plan should be updated after each fall with appropriate intervention.On 1/22/26 at 12:00PM, V1(Administrator) said his expectations are for the care plans to be updated after appropriate interventions are discussed for the residents.Facility Policy Comprehensive Care Plan, revised 11/17/25Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being.Guidelines: the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that includes measurable objectives and timeframes to meet a residents medical, nursing and mental and psychosocial needs that re identified in the comprehensive assessment.

Based on observation, interview, and record review the facility failed to implement fall preventive measures for a resident who is a high fall risk. This deficiency affects one (R5) of three residents reviewed for Fall prevention program.Findings include:R5 is a [AGE] year-old with the following diagnosis :chronic respiratory failure with hypoxia, encounter for attention to tracheostomy, dependence on respiratory ventilator status, encounter for attention to gastrostomy, displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, essential hypertension, other seizures, anxiety disorder, adjustment disorder with depressed mood, major depressive disorder, generalized edema, pain in left hip, diaphragmatic hernia without obstruction or gangrene, delirium due to known physiological condition.Facility reported incident indicates on 10/21/25 R5 was observed laying on the floor on his left side by facility staff. R5 denied hitting head and level of conscious remained at baseline of Alert and orientated times person, place. R5 reported pain to the left lower extremity. Limb was immobilized and pain medication was administered as ordered by the physician with verbalized relief. Physician notified of the fall and new pain complaint; order received to obtain an x-ray of the left lower leg. X-ray results indicated an acute intertrochanteric fracture of proximal left femur. Physician was updated on the findings and gave further orders to transfer R5 to the hospital for further evaluation and treatment.On 1/20/26 at 1:00PM, R5 observed in room, laying in bed, with one floor mat to the right side of bed, no left side floor mat observed next to R5 bed. On 1/20/26 at 1:00PM, V16 (Assistant Director of Nursing) said that she moved the floor mat on the left side of bed to place the bedside table so that R5 can eat lunch. V16 said she will come back to room once he is done eating.On 1/20/26 at 2:42PM, V2 (Director of Nursing) made aware that V16 removed floor mat to left side of bed for R5 who was in bed, eating lunch, and left in room unsupervised. V2 said that R5 should be up from bed and in wheelchair placed in high visible areas to be monitored, because he is a high fall risk.R5's Fall Risk scale dated 10/26/25 indicates High risk for falling.The Care Plan dated 2/27/25 documents R5 is at high risk for falls gait/balance problems, poor communication/comprehension, decreased safety awareness, and adverse behaviors: interventions in place include 2/27/25-keep furniture in locked position,6/20/25 -educate resident to use call light for assistance with toileting and ADL's, 10/21/25- Bilateral floor mats. 11/29/25-no intervention, 12/1/25-no intervention.Facility Policy on Fall Prevention Program, revised 11-21-17Purpose:To ensure the safety of all residents in the facility, when possible. The program will measure which determine the individuals need of each resident by assessing the risk for falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness.Guidelines:-use and implementation of professional standards of practice-communication with direct care staff members-Care plan incorporates:Address each fallInterventions are changed with each fall as appropriateStandards:-Safety interventions will be implemented for each resident identified at risk.Fall/safety interventions may include but are not limited to:-the bed will be maintained in a position appropriate for resident transfers.-Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan.

Based on observation, interview and record review the facility failed to ensure that a feeding tube was administered as ordered for one resident (R8) reviewed for tube feedings.Findings include:On 1/20/20/2026 at 12:33pm R8 said I have a tube feeding and I do not want it on when I'm eating, the nurse has not started my tube feeding at all today.On 1/20/2026 at 2:15pm V2 said I expect for all tube feedings to be administered as ordered or the nurse practitioner notified to adjust the feeding to the resident preference.On 1/21/2026 at 10:12am V10 said R8 does refuse his feeding during his meals, I do expect the feeding to be administered when he is not having his meals by mouth. An admission record dated 1/2-0/2026 indicates that R8 has a diagnosis of Chronic Respiratory Failure, tracheostomy, liver transplant, gastrointestinal placement, seizures, an order summary report for Enteral feed order dated 11/15/2025 for Nepro 1.8 rate of 45 milliliter's an hour for 24 hours total volume 1,080 ml. A care plan dated 11/15/2025 intervention to administer tube feeding as ordered.Facility Policy: Enteral Nutrition (EN)-Tube FeedingGuideline: Enteral Nutrition (EN) may be instituted for individuals who have an intact gastrointestinal tract but are unable or unwilling to take food by mouth in amounts that will support adequate nutrition. Such as individuals with neurological disorders (strokes, head and neck trauma or surgery), cancer and individuals with difficulty swallowing or ingesting adequate amounts of food, and gastrointestinal obstructions.Nursing staff will follow the community enteral nutrition policies and guidelines.Administration of Enteral FormulaContinuous drip: Requires a pump and is appropriate for individuals who do not tolerate larger volumes of tube feeding (TF) infusions.8. Close monitoring of the tube feeding tolerance, intake and output records, nursing notations on physical assessment.11. Enteral feeding schedule suggests steps in determining an enteral feeding schedule.13. Monitoring of the individual's actual intake and tolerance of tube feeding is important to ensure that nutritional goals are met and maintained. Monitoring the individuals with tube feeding is an interdisciplinary team effort and includes.A. EN is being delivered as ordered by the physician

Based on observation, interview, and record review the facility failed to follow physician's order for oxygen administration affecting one (R6) of three residents reviewed for oxygen administration. Findings include: R6 was admitted on [DATE], with diagnoses listed in part but not limited to Alzheimer's disease, Dementia, adult failure to thrive, type 2 diabetes mellitus, chronic ischemic heart disease.Physician active orders: no order for oxygen use. On 1/21/26 at 10:25AM, R6 observed in room laying down, with oxygen in use, at 2L per nasal cannula, tubing with no label date.On 1/21/26 at 10:25AM, V3 (Wound Care Coordinator) said that the oxygen tubing should have a label with the date to indicate when it was changed to make sure it is clean and for infection control purposes.On 1/21/26 at 10:44AM, V2 (Director of Nursing) made aware of above findings and said that the oxygen should have a physician's order for administration and tubing should be labeled with date.On 1/21/26 at 1:30PM, V1 (Administrator) made aware of R6 with oxygen in use and no physician order or label on tubing with date, and no care plan for oxygen in use. Facility Policy on Oxygen Therapy- last revised 12/1/2021.Purpose: to deliver oxygen in condition in which insufficient oxygen is carried by the blood to the tissues. Indications for oxygen use via supplemental oxygen delivery devices include:-reverse the effects and symptoms of hypoxia-decrease respiratory and cardiovascular workload.PolicyIt is the policy of this facility that oxygen shall be used in a safe and effective manner in accordance with applicable rules and regulations and the standard of care.Procedure:Physician orderVerify physician order.11. Set- up and administration of oxygenE. Discard disposable mask, cannulas, and tubing after use in accordance with equipment change schedule.

Based on interview and record review the facility failed to ensure that medications were administered as ordered by a physician, for two (R5 and R8) of two residents reviewed for medication administration.Findings include:On 1/20/2026 at 12:33pm R8 said I have not received my morning medications. The nurse said she would give them to me along with my 12:00 noon medications. Its lunchtime and after 12:30pm and I have not gotten them as of now. On 1/20/2026 at 2:15pm V2(Director of Nursing-DON) said I expect the nurses to follow the physician orders and administer medication as prescribed. On 1/20/2026 at 2:30pm V7(Licensed Practical Nurse-LPN) said she was running late this morning and that she had not had a chance to administer his morning medications, V7 said I understand it should be given an hour before and an hour after our start time and I will notify the nurse practitioner and inform her of the medication being administered late. On 1/21/2026 at 10:12am V10(Nurse Practitioner-NP) said R8's medications should be administered as ordered, administering both morning and noon could cause gastrointestinal upset, loose stools and abnormal medications. An admission record dated 1/2-0/2026 indicates that R8 has a diagnosis of Chronic Respiratory Failure, tracheostomy, liver transplant, gastrointestinal placement, seizures, an order summary report for Enteral feed order dated 11/15/2025 for Nepro 1.8 rate of 45 milliliter's an hour for 24 hours total volume 1,080 ml, Keppra 500milligrams two tabs two times daily for seizures, metoprolol 25milligrams two tabs in the morning and at night, tacrolimus 1milligram -3 tabs two times a day for organ rejection. A care plan dated 11/17/2025 to administer medications as ordered. Facility Policy: Medication Administration Effective date 10/25/2014 Policy Medications are administered as prescribed in accordance with good nursing principles and practices only by people legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. B. Administration 2. Medications are administered in accordance with written orders of the prescriber. 12. Medications are administered within 60 minutes of scheduled time; routine medications are administered according to the established medication administration schedule for the facility. R5 is a [AGE] year-old admitted on [DATE] with the following diagnosis :chronic respiratory failure with hypoxia, encounter for attention to tracheostomy, dependence on respiratory ventilator status, encounter for attention to gastrostomy, displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, essential hypertension, other seizures, anxiety disorder, adjustment disorder with depressed mood, major depressive disorder, generalized edema, pain in left hip, diaphragmatic hernia without obstruction or gangrene, delirium due to known physiological condition. Order summary report for ferrous sulfate tab 325mg 1 tab in the morning, Valproic acid oral solution 500mg/ml give 10ml by mouth two times a day, clonazepam 2mg tablet give 1 tablet by mouth three times a day. A care plan dated 2/21/25 give medications as ordered. On 1/20/26 at 12:30PM, R5 observed in bed and said he is unsure if he got his medications, usually he does. On 1/20/26 at 2:45PM, V11 (Licensed Practical Nurse) said she is supposed to sign off the medications immediately after administering them, said she doesn't know why she did not do it when she administered them at 9:00am for R5.

Based on interviews and record review, the facility failed to protect a resident's (R1) right to be free from physical abuse from an employee for one (R1) of four residents reviewed for abuse in a sample of four. This failure resulted in R1, who is severely cognitively impaired, being physically assaulted by an employee and experiencing pain. R1, as a reasonable person would not expect to be harmed in their own home or health care facility, causing them to feel fear, anxiety, and anger. Findings include: R1 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Unspecified Dementia, Unspecified Severity, With Other Behavioral Disturbance; Other Seizures; Essential (Primary) Hypertension; Insomnia, Unspecified; Anxiety Disorder, Unspecified; and Mild Hyperemesis Gravidarum. According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 3 indicating severe cognitive impairment. R1's memory impairment care plan dated 12/13/2024 reads in part, (R1) activity involvement is limited as a result of cognitive, memory impairment. (R1) leaves during activities, resists, refuses invitations to programs, spends her leisure time out in the common area watching television. Interventions: Involve (R1) in programming for cognitively impaired persons, as appropriate. Programs may include sensory awareness, sensory stimulation and/or sensory integration. Use resources and lesson plans emphasizing these techniques for reaching and connecting with this population. Absent are R1's communication barriers care plans prior to the incident on 03/23/2025. Absent are R1's dementia care plans prior to the incident on 03/23/2025. Absent are R1's abuse care plans prior to the incident on 03/23/2025. On 03/24/2025 at 11:32 AM V5 (Anonymous Visitor) said, On 03/23/2025, I was visiting my relative in the facility. Around 8:12 PM, I went to the third-floor unit and that's when I saw (V8 Licensed Practical Nurse/LPN) punching (R1) twice. I asked if (R1) was ok, she responded (V8 LPN) hit her twice. Allegedly, (R1) grabbed (R2's) oxygen tubing as she was trying to get through and (V8 LPN) came up to (R1) and punched the right side of her upper back. There was no other staff present. It happened right by the nursing station. I reported it to V6 (Restorative Director/Manager on call) and they assured me that (V8 LPN) will be leaving with handcuffs on if not willingly, and that they will call the police. About an hour later, I followed up with the local police department, but they had no report of the incident. I also reported it to V1 (Administrator/Abuse Prevention Coordinator). On 03/24/2025 at 12:45 PM V6 (Restorative Director/On Call Manager) said, I got a phone call from V7 (Licensed Practical Nurse) stating that the V5 (Anonymous Visitor) came down and voiced some concerns and that she will let me speak to V5 over the phone. V5 said that she witnessed V8 (LPN) hit R1. V5 further said that she tried to pull out her phone to record a video, but she didn't do it quick enough and only recorded the after effect. I told V5 that I will call V1 (Administrator/Abuse Prevention Coordinator) and V2 (Director of Nursing). I immediately removed V8 (LPN) from the third-floor unit and drove over to the facility. The only discussion I had with V8 (LPN) was to gather his belongings, punch out and leave immediately. I came to the facility around 9:45 PM. I went to assess R1. R1 had no injuries, no bruising, no redness, no raised areas. I talked to R1 but her BIMS (Brief Interview of Mantal Status) is 3, so her response to my question was not appropriate. I asked if R1 was ok, she said, she was ok. R1's vital signs were stable. The only concern R1 had was pain in the right scapula, R1 rated it at 3. It was a new pain. I gave R1 pain medication. I checked on R1 again within 45 minutes and she was asleep. I notified on call nurse practitioner of the incident and received an order to continue pain management and monitoring. On 03/24/2025 at 1:11 PM Surveyor observed R1 sitting up in the bed in R1's room. R1 appears relaxed and calm. When asked if R1 was hit or pushed last night (03/23/2025), R1 said, I don't know. R1 denies any pain to the right side of her back at this time. On 03/24/2025 at 1:44 PM V1 (Administrator/Abuse Prevention Coordinator) said, I got a call from V6 (Restorative Director/On Call Manager) last night (3/23/2025) at around 8:30 PM. V6 said she was calling to report an allegation of abuse. I asked V6 what happened, V6 said V5 (Anonymous Visitor) said that V8 (Licensed Practical Nurse) punched R1 on the back. I made sure V8 (LPN) was removed from the duty and R1 was assessed and is doing ok. I told V6 I will be coming to the building shortly. I spoke to V8 (LPN) on the way to the facility. V8 (LPN) said that he was at the nursing station, R2 was on the left side of the common area and R1 was sitting on the couch behind R2, which was around the same area. V8 (LPN) had to redirect R1 from playing with R2's oxygen tubing several times. V8 (LPN) then got up with intention of moving R1. As he attempted to move R1, V8 (LPN) heard voice yelling: You hit her! You hit her! V5 (Anonymous Visitor) actually said that V8 (LPN) punched R1. V8 (LPN) denied the accusation. I got to the facility around 9:45 PM. V8 (LPN) was gone by then and I just followed our abuse protocol. I checked the schedule to see what other staff was working, I interviewed, the other nurse who was on the floor, spoke to all CNAs (Certified Nurse Assistants), and supervisor who called me. I interviewed R1, R1 was in bed at that time, R1 said she didn't remember of anything happened, denied being hit and said she is ok. I called V16 (Family Member), left her a voicemail saying what happened. I also notified the local police to report the allegation. The investigation is still ongoing. On 3/24/2025 at 2:48 PM V7 (LPN) said, I worked last night (3/23/2025 between 3:00 PM -11:00 PM). At around 8:15 PM, V5 (Anonymous Visitor) came down and told me that (V8 LPN) struck (R1). V5 was trying to tell me that she didn't pull out her phone quick enough to record the incident but showed me the after effect recording of what happened. Surveyor asked what was V7's (LPN) impression of the incident recorded in the video, V7 (LPN) said, My impression of the video was that I had no words because V5 should have not been recording people without their consent. I recognized V8 (LPN) and R1 in the video. V8 (LPN) was denying hitting R1 upon V5's confrontation. V5 asked R1 and she confirmed she got hit twice. V8 (LPN) was then demonstrating what he did and R1 flinched a little when V8 (LPN) was swatting his hand by R1's right side. Surveyor asked if V8 (LPN) behaved appropriately in the video, V7 (LPN) said, I don't think what V8 (LPN) did was appropriate. After I watched the video, I called V6 (Restorative Director/On Call Manager) and told her what happened. V6 confirmed understanding, asked V5 to the phone and, right after that, told V8 (LPN) to leave the facility. On 3/24/2025 at 3:01 PM V2 (Director of Nursing) said, V5 (Anonymous Visitor) sent me a recording of the incident from last night (3/23/2024). When I saw the video, I thought it was intrusive to record residents in the facility. I notified V1 (Administrator/Abuse Prevention Coordinator) who was already aware of the incident and then I called V5 back and asked about what she sent me. V5 said, I saw (V8 LPN) hit (R1). On 3/24/2025 at 3:37 PM V10 (Certified Nurse Assistant) said, I worked on the third-floor unit on 3/23/2025 from 3:00 PM to 11:00 PM. I was at lunch break at the time of the incident, so I didn't see what happened. I remember, R1 and R2 were staying in the common area by the nursing for most of the afternoon and R1 was constantly playing with R2's oxygen tubing. I had to redirect it multiple times. On 3/24/2025 at 3:52 PM V8 (Licensed Practical Nurse) said, I worked on the third-floor unit on 3/23/2025 from 3:00 PM to 11:00 PM. R1 was not in my assignment but I cared for her multiple times in the past. After dinner, R2 was sitting in the wheelchair in the common area by the nursing station with his oxygen concentrator connected to the electric outlet in the wall. R1 came over to sit on the couch, right behind R2. R1 was attempting to pull the oxygen tube and disconnect oxygen concentrator from the electric outlet, so I redirected her. R1 did it a couple more times, so I finally came up to R1, and took the oxygen tubing away from R1. I leaned over R1, put my hand at her back and told R1 to leave the tubing alone. At the same time, V5 (Anonymous Visitor) started yelling. At first, I didn't realize she was yelling at me. V5 was yelling that I hit R1. I was trying to show V5 what happened, but I never hit R1, I had no reason to do it. V5 pushed R1 to say I hit her. After that, V5 left the unit, and shortly after, I received a call from V6 and was told to leave the facility. I gave my statement over the phone. I never got frustrated with R1, R1 is confused, I understand that. V8's (LPN) description of the incident shows that the physical contact V8 (LPN) made with R1 at the time of the incident (03/23/2025 8:12 PM) was unwarranted and punitive due to circumstances described by V8 (LPN). On 03/25/2025 at 12:39 PM Surveyor reviewed facility recording of the third-floor common area with time stamp of 3/23/2025 8:12 PM. Surveyor observed V8 (LPN) sitting at the nursing station, picking his head up and talking towards the area where R1 was sitting. R2 visible in the video as well. V8 (LPN) proceeds then to walk quickly walk over towards R1. Camera picture cuts off the area where alleged incident occurred. Surveyor unable to observe the alleged incident on the presented recording. On 3/25/25 at 12:46 PM V19 (Family Nurse Practitioner) said, I cannot tell you what happened at the time of alleged incident, I wasn't in the facility. I came in yesterday (3/24/2025) before lunch time, V2 (Director of Nursing) made me aware of the video, I didn't see it the video though. I assessed R1, R1 was stable, she was not aware of what is going on. R1 was not in pain yesterday. R1 does not have any chronic pain and is able to express acute pain. I wasn't made aware that she had pain in the right scapula post the incident nor that she received pain medication for the post incident pain. On 3/25/2025 at 1:18 PM In the follow up interview, V1 (Administrator/Abuse Prevention Coordinator) said, When V8 (LPN) first saw R1 getting 'busy' that day (3/23/2025), V8 should have gotten an activity staff involved. R1 could have been occupied with activity board or folding towels, something to get R1 engaged. Also, when R1 was sitting in the same area with R2, V8 (LPN) could have moved R1 sooner seeing her fixation with the oxygen tubing. V8 (LPN) should have given R1 other things to get occupied with to have to redirect her less. You find residents where they are, if you know that this is a behavior that she's having, V8 (LPN) should have thought what I need to do to decrease R1's fixation on that tubing or cord. Maybe V8 (LPN) could have reached out to the facility to encourage family to visit. When confronted by V5 (Anonymous Visitor), V8 (LPN) should have notified the supervisor right away instead of engaging with V5. On 3/25/2025 at 1:52 PM V16 (R1's Family Member) said, I met with V1 (Administrator/Abuse Prevention Coordinator) yesterday (3/24/2025) and requested to see facility's video that was recorded in the facility. I'm not comfortable with what happened. I understand there was an individual who recorded R1 and that makes me uncomfortable. Also, something must have happened that made the individual to start recording, something must have triggered them to do it. R1 said in the recording that's floating in social media that the nurse hit her twice. I am concerned with R1's safety until I find out what happened. When I saw the recording, V8 (LPN) appeared agitated, not sure if it was because he was getting recorded or because he just hit R1. Facility Reported incident dated 03/23/2025 reads in part, On Sunday, March 23, 2025, at approximately 8:45 PM (V5 Anonymous Visitor), alleged that (V8 Licensed Practical Nurse) struck (R1). V5 reported the allegation to (V6 Restorative Director/On Call Manager). V6 reported to (V1 Administrator/Abuse Prevention Coordinator). (V8 LPN) was immediately removed from the facility. (R1) was assessed with no signs of physical injury. Investigation initiated. (R1) safe in the facility. Police notified. Family and physician notified. Police report requested on 03/25/2025, unable to obtain it during course of the survey. V6's progress note dated 03/23/2025 11:14 PM reads in part, Writer performed a skin assessment on (R1) no areas of concern noted No bruising, redness, noted. (R1) stated she had pain to right scapula. ROM within normal limits. (R1) medicated for pain by assigned nurse. Writer made on call N/P (Nurse Practitioner) aware of incident stated to continue PRN (as needed) pain medication as needed and to continue to monitor. R1's Comprehensive Pain Observation (New) dated 03/23/2025 10:00 PM reads in part, Reason for evaluation: New report of pain; Information obtained from: resident; Presence of Pain: Does the resident exhibit signs or symptoms of pain, verbalizes the presence of pain, or requests interventions for pain? Yes; Pain Level: 3. R1's March 2025 Medication Administration Record shows pain medication administered on 03/23/2025 at 10:01 PM for pain on level 3. The facility Abuse Prevention and Reporting - Illinois policy last revised on 10/24/2022, reads in part, 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 an training employees on how to deal with stress and difficult situations, and how to recognize and report of abuse, neglect, exploitation, and misappropriation of property; Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on interview and record review, the facility failed to transfer one resident to the hospital after a new onset of pain and abnormal x-ray results for an acute fracture. This affected one of three residents (R2) reviewed for radiology results, and nursing assessments. This failure resulted in R2 having increased pain and a 5 day delay in sending R2 to the local hospital for treatment. Findings Include: R2 has diagnoses of Osteoarthritis, Syncope Episode, Radiculopathy, Raynaud's syndrome and a fall with Right hip fracture. Physiatry Progress noted dated 2/7/25 documents: Service date: 2/6/2025 documents: The patient (R2) was seen and examined today. Received R2 today up in the bed with complaints of pain to her right hip. Tenderness to touch. This is an old right hip surgery. R2 reporting new-onset pain. R2 has limited range of motion to that right leg with pain. R2 was amenable to an x-ray to the right hip. Assessment: Recent right hip fracture/fracture care. Right leg contracture. New-onset right hip pain. X-ray PA and lateral pending. Radiology results report dated 2/7/25 documents: Postersuperior dislocation of the right prosthetic femoral head with acute fracture of the posterior right acetabular (socket of the hip joint) wall. The femoral head prosthesis remains in good position with the femur. Pronounced osteopenia. Most probably is a pathological fracture due to advanced osteopenia. On 2/27/25 at 12:18pm, V3 (Nurse) said, she received the x-ray results. V3 said, she relayed the result to V20 (Medical Doctor) who did not give any new orders. V3 said, she did not assess R2 at that time. V3 said, she merely relayed the results to the doctor and nothing more. Physician order sheet dated 2/6/25 documents: Right hip, unilateral with pelvis when performed 203 views. Sent for imaging 2/6/25 5:05PM central time (CT). Radiology note dated 2/7/25 document: Right hip x-ray relayed to V20 (medical doctor). No new orders. On 2/27/25 at 12:45PM, V2 (Director of Nurses/DON) said, R2 was seen by V15 (Nurse Practitioner/NP) on 2/6/25. R2 did not have any new pain. R2 had a pervious fracture to that right hip. R2's pain was at baseline. V16 ordered an x-ray. V3 (Nurse) called V20 (Medical Doctor) with the results. V2 said, V20 did not given any new orders. V2 said, she was not aware of R2's x-ray results at that time. V2 said, she reviewed R2's x-ray results saw it documented an acute fracture. V2 said, she used her nursing judgement, called the doctor for an order to transfer R2 to the hospital. R2 denied incident. On 2/27/25 at 3:55PM, V2 said, she would have verified the x-ray results with V20 to ensure he heard what she read. V2 said, R2 should have been sent to the hospital when the x-ray was received. V2 said, she should have been notified. V2 said, she would have made the call to send R2 to the hospital if she had been notified. V2 said, she expected V3 to notify her of R2's fracture. V2 said, V3 is being placed on a performance action plan which includes a focused assessment. V2 said, V3's performance action plan was not complete or available for review during this survey. On 2/28/25 at 2:32PM, V20 (Medical Doctor) said, he instructed the nurse to get R2's previous x-ray for comparison. V20 said, it was late Friday when he got the call about R2's x-ray results. V20 said, it was over the weekend and the facility could not get R2's previous x-ray. V20 said, he was told R2's fracture might be a new. V20 said, he instructed the facility to send R2 to the hospital. V20 said, V2 mentioned, something might have happened during therapy. It might have occurred with therapy when R2 was being transferred from the bed to the chair. If R2's fracture was new it should have fractured at the femur first. Physician Progress note dated 2/11/25 documents: R2 was complaining of right hip pain. R2 was at baseline. R2 denies any falls. Per x-ray of R (right) hip/pelvis, showed advanced osteopenia right femoral head. Prosthesis was in good position; however, it did show posterior/superior dislocation of right prosthetic femoral head with acute comminuted fracture of Right acetabulum. Assessment: Right prosthesis dislocation. Progress note dated 2/11/25 documents: R2 transferred to the hospital for evaluation of right hip prosthesis dislocation and increasing pain. R2's physician order sheet dated 2/11/25 documents: Transfer resident to the hospital. Facility incident report dated 2/11/25 documents: Injury type: Fracture. R2 denied any incidents or falls that occurred in the facility. Runsheet dated 2/11/25 documents: Dispatched to nursing home, for R2 with a possible hip fracture. R2 was favoring her left hip due to pain. Assessment on R2 revealed nothing abnormal other than some pelvic pain. Primary Impression: Pain (acute) due to trauma. Hospital paperwork dated 2/11/25 documents: R2 present with right hip pain and deformity status post aggressive transferring in the bed at the nursing home two weeks ago. R2 has not ambulated in three weeks because nursing home restricted her from walking. R2 baseline is alert times two. Imaging yesterday shows posterior/superior dislocation of right prosthetic femoral head with acute comminuted fracture of Right acetabulum wall. R2 denied any recent fall or trauma to her right lower extremity. Review of systems: Positive right hip pain. Comments: Right hip tenderness to palpation. Musculoskeletal: right hip deformity.

Based on interview and record review, the facility failed to provide a safe enviroment while providing direct incontinence care. This affected one of three residents (R8) reviewed for saftey while providing care. This resulted in R8 losing his balance and falling to the floor and sustaining a left hip fracture requiring surgical intervention. Findings Include: R8 has diagnoses of Alzheimer's Disease, Syncope And Collapse, Hypertension, Dementia without Behavioral Disturbance and Anxiety, Lack Of Coordination, Difficulty In Walking, Weakness and Cognitive Communication Deficit. Minimal data set section C (cognitive pattern) dated 1/16/25 documents a score of three which indicated severe cognitive impaired. Section GG (functional abilities) documents: R8 requires supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently with toileting hygiene and walk ten feet. Care plan initiated 11/30/22 documents: R8 is at high risk for falls related to decreased mobility, balance and endurance. Fall assessment dated [DATE] documents: R8 was at moderate risk for falling for overestimate or forget limits. On 2/28/25 at 1:37PM, V21 (Certified Nurses Assistant/CNA) said, V21 was providing incontinence care for R8 after a bowel movement. V21 said, R8 was standing up next to his bed. V21 said, she removed the tape/sides of R8's adult brief. R8 can walk a little. V21 said, she started cleaning R8's buttock, asked R8 if he had to urinate to which R8 replied, no. While standing up R8 started too urinated. V21 said, she jumped back, urine came out of nowhere. V21 said, some urine got on her pant leg. R8 had on socks, he attempted to ambulate, walk toward V21 to go to the bathroom but slipped in his urine. V21 said, she attempted to grab R8 but could not. V21 said, she did not lower R8 to the floor. V21 said, she could not reach R8 after she moved out of the way. V21 said, the space she was providing incontinence care was tight, very little room. Fall incident dated 2/14/25 documents: R8 was observed on his back near his bed. Mental status: oriented to person. Predisposing environmental factor: wet floor, Predisposing Physiological factors: confused, gait imbalance, impaired memory and incontinent. Predisposing situation factor: other-prostate cancer with frequent urination. R8's nursing note dated 2/14/25 documents: At 6:30am writer summoned by staff (V21) to the resident room. Resident observed on his back near his bed. When asked what happened. The resident was unable to state. V21 stated that resident was slipping on urine and I tried to prevent him from falling by easing the resident to the floor. Order of an x-ray of the right hip and leg received and carried out. On 3/4/25 at 11:27AM, V2 (Director of Nurses/DON) said, incontinence care should be done on the bed or in the bathroom. If R8 had to stand up to be cleaned, he should have been in the bathroom, holding onto to the rail for stability. V21's counseled regarding: standard of conduct: Performing work in an unsafe manner and poor work performance. Any time a resident is gotten out of bed staff are required to apply foot (non-skid slippers, shoes). Required Corrective Action: Immediately improvement with adherence to safety is required when assisting resident out of bed. On 3/5/25 at 12:29PM, V22 (Nurse) said, R8 was on his back on the floor when he entered R8's room. R8 did not have any abnormalities to the eye. R8 was not wearing any socks or shoes. R8's left hip was painful to touch. R8's room was very small. V22 said, there was nothing for R8 to hold on too when he was standing up. V22 said, R8 urinated and slipped in his urine. Subsequent visit dated 2/14/25 documents: Patient (R8) was seen today after he had slipped down while CNA attempted to assist patient back to bed. He had urinated on floor and slipped in the urine during transfer. He was laid onto the floor and Nursing completed head to toe exam. No injuries found. X-rays ordered of bilateral hip and knees. Fall on same level from slipping, tripping and stumbling without subsequent striking against object. X-ray dated 2/14/25 documents: Acute nondisplaced left femoral intertrochanteric fracture. Facility final reportable dated 2/20/25 documents: R8 experienced a witnessed fall. Per nurse on duty, while staff was administering patient care, R8 began to urinate on the floor, then attempted to ambulate to the restroom in his room losing his balance and began to fall. Staff attempted to stop resident from walking but was unsuccessful. R8 was eased to the floor. Staff observed R8's left lower extremity with irregular positioning. Affected limb immobilized. R8 complaint of pain to his left leg. Hospital paperwork dated 2/14/25 documents: R8 was brought in secondary to left hip pain after fall at the nursing home. CT lower left extremity dated 2/14/25 documents: Suspected Stress fracture. Acute comminuted intertrochanteric fracture of the left femur with impaction of the fracture segment requiring a left intramedullary nail (metal rod inserted into the thigh bone to treat fracture). Fall Preventive Program dated 11/28/12 documents: To assure safety of all residents in the facility, when possible. Use and implementation of professional standards of practice.

Based on interview and record review, the facility failed to have pain medication available Hydrocodone-acetaminophen PRN (as necessary). This affected one of three residents (R6) reviewed for pain. This resulted in R6 being without pain medication and stated she was in extreme pain for about 1 day. R6 was status post laminectomy. Findings Include: R6 has a diagnosis of Spinal stenosis, lumber region with neurogenic claudication, lumbago with left side sciatica and Osteoarthritis. Brief interview for mental status dated 1/21/25 documents a score of 15 which indicates cognitively intact. Nursing note dated 1/16/25 documents: resident (R6) was admitted post lumber laminectomy (surgery to ease pressure on the spinal cord and nerves of the lower spine). On 2/28/25 at 10:32AM, R6 who was assessed to be alert and oriented to person, place and time said, she was admitted after having back surgery. R6 said, she was in extreme pain for two or three days with no relief from the pain patch and muscle relaxer. R6 said, the nurse failed to refill her Hydrocodone-acetaminophen when there was only five pills left in the bingo card. R6 said, her pain was so bad she cried. On 2/28/25 at 3:32PM, V12 (Nurse) said, R6 was out of pain medication for one day. R6 complained of pain. R6 had muscle relaxants. R6 was p*ssed. V12 said, she offered R6 acetaminophen and muscle relaxant but R6 refused both medications. R6 wanted Hydrocodone-acetaminophen. Control Drug Receipt/Record/Disposition Form dispensed dated 2/2/25 documents: quality dispensed -thirty, (2/13/25) documents: amount given one, amount left zero. Nursing note dated 2/14/25 documents: R6 left facility going to appointment. R6 complained of pain writer offered resident, as needed acetaminophen, R6 refused medication times two nurses are present at bedside. Nursing note dated 2/14/25 documents: As need muscle relaxant was offered, resident refused. This writer contacted pharmacy for as needed medication order status, writer was transferred to the pharmacist for STAT order delivery, initial attempt was unsuccessful, writer is redirected and spoke with pharmacist, pharmacist directed writer to remove medication from nexus and contact pharmacy for code once medication is required. On 2/28/25 at 11:33AM, V23 (pharmacy) said, we needed a new prescription for R6's Hydrocodone-acetaminophen on 2/13/25. We received a prescription on 2/13/25. A thirty day supply of Hydrocodone-acetaminophen pills was sent to the facility on ,d+[DATE].25. On 3/4/25 at 12:36PM, V2 (Director of Nurses/DON) said, R6's Hydrocodone-acetaminophen pain medication was not removed from the nexus. V2 said, she does not have the Control Drug Receipt/Record form with the nurse's signatures on it dated 2/15/25 from R6's delivered medication. Physiatry progress note dated 2/14/25 documents: service date 2/13/25- Received patient (R6) today up on the side of the bed with complaints of pain to her back, requesting a Norco (Hydrocodone-acetaminophen). She continues to report that Norco provides acceptable pain relief. Medication Administration record dated 2/1/25- 2/28/25 documents: Hydrocodone-acetaminophen oral tablet 5-325mg -give 1 tablet by mouth every four hours as needed for pain. Thursday 2/13/25 last dose of medication given was documented at 2:29pm. Pain scale dated 2/13/25 (11:23pm/11:24pm) documents a pain scale of five out of ten. No medication was documented given for 11:23/11:24 pain scale. R6's pharmacy packing slip proof of delivery dated 2/15/25 documents: Drug name: hydrocodone-acetaminophen 5-325mg (milligrams), quality thirty pills delivery time at 6:33am. Control Drug Receipt/Record/Disposition Form dispensed dated 2/15/25 was requested from V2 (DON) and not provided/available during this survey. Pain Assessment Policy dated 11/28/12 documents: to establish guidelines for appropriate and intervention to manage pain. Medication will be administered at specific request of the patient and when the patient refused other such interventions.

Based on interview and record review, the facility failed to follow their physician notification of laboratory/radiology/diagnostic results policy by not notifying the physician/nurse practitioner of a sacral wound culture results indicating high amount of bacteria (greater than 100,000 pseudomonas aeruginosa) for one resident (R2) who had a stage three sacral pressure ulcer. This affected one of three (R2) residents reviewed for notification of an abnormal lab result. This failure resulted in R1 not receiving any antibiotic treatments and being hospitalized two weeks later with a diagnosis of sacral osteomyelitis. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of sepsis, pressure ulcer of sacral region stage three, quadriplegia, anemia, muscle wasting and adult failure to thrive. R2's wound assessment dated [DATE] by V14 (Wound NP/Nurse Practitioner) documents: pressure injury stage three to coccyx measuring 5 centimeters (CM) length x 4CM width x 0.1cm depth. 60 % granulation and 40 % sloth. Signs and Symptoms of Infection: documents odor. Comments: obtain wound culture and labs, consult Infectious disease. R2's progress note dated 10/3/24 documents, seen per wound MD (Medical Doctor) with coccyx assessed with positive malodor and onset green tinge to drainage, wound culture obtained, V17 (Infectious Disease/ID, NP) consult initiated, V17 (ID NP) notified. On 11/1/24 at 11:28AM, V15 (previous Wound Care Coordinator) said she recalls R2's wounds declining and ordering wound culture. V15 said usually V17 (NP) will follow up with the results and order an appropriate treatment. V15 said she is not sure what happened and does not recall any other information related to R2's culture result. V15 said she does not recall informing or following up with anyone related to R2's wound culture results. On 10/31/24 at 12:34PM, V17 (ID NP) said he did receive a message for consult on 10/3/24 but unsure why R2 was not seen. V17 said usually the ordering physician would be notified of culture results. V17 said he was not aware of R2's wound culture results and would have ordered antibiotics for R2. On 10/30/24 at 2:55PM, V14 (previous Wound MD) said her last visit with R2 was on 10/3/24 and she did not return for any services at the facility. V14 said she ordered the wound culture due to wound declining and signs of infection. V14 did not receive any culture results for R2. V14 said at the facility they will consult Infectious Disease for further management to determine right antibiotic. V14 said she would usually follow up the next visit to see what antibiotic the patient was on or follow up with results. V14 said it is possible for the wound to get worse if there was an infection but unable to determine exact cause of infection. R2's facility wound assessment report dated 10/4/24 documents: stage 3 pressure ulcer. Under odor and signs of infection present it documents yes. R2's wound care note dated 10/11/24 by V13 (Wound NP) documents sacral pressure ulcer stage 4 measuring 8 centimeters (CM) length x 8.5 cm width x 2 cm depth. Necrotic tissue 90% slough 10%. wound debrided post debridement size measuring 8 centimeters (CM) length x 8.5 cm width x 2.3 cm depth. On 10/30/24 at 1:32PM, V13 (Wound MD) said his initial visit of R2 was on 10/11/24. V13 said he was not notified of any culture results for R2 at time of visit or after. On 10/31/24 at 1:28PM, V2 (DON/Director of Nurses) said for wound culture orders, the wound care nurse would obtain culture and send out to the lab. Floor nurse would receive the results and relay the results to primary care physician who would determine any orders. On 10/31/24 at 2:15PM, V2 (DON) said she did receive an email for R2's culture result but unsure what happened with the follow up. On 11/1/24 at 11:44AM, V19 (MD) said he does not recall getting notified of wound culture results for R2. Usually, the ordering physician is notified of the results, but staff should always call him with any results. If there was a need for treatment V19 said he would have ordered the appropriate antibiotics but sometimes the culture can be colonized, and treatment is not needed. Osteomyelitis can occur from the wound progression and infection. R2's development of osteomyelitis can be a combination of both infection and declining wound status and unable to determine the exact cause. V19 said there should have been sooner intervention in relation to the wound culture results but unable to determine if the interventions were placed if R2 would have not gotten osteomyelitis given the overall wound progression. R2's medical record under lab results documents wound culture collected 10/3/24, reported date 10/7/24 with reviewed status. Wound pathogen panel dated 10/7/24 documents: pseudomonas aeruginosa, staphylococcus aureus and streptococcus agalactiae detected. Positive. Printed 10/11/24. R2's final lab report dated 10/7/24 documents: coccyx wound culture results indicating high amount of bacteria greater than 100,000 of pseudomonas aeruginosa. V14( previous Wound NP) is listed as physician. On 11/1/24 at 9:04AM, V18 (Lab Director of Operations) said results were sent to facility on 10/7/24 but the whole report did not send. V18 said the full results were emailed to the facility on [DATE]. V18 said they will recommend treatment for any result indicating high. R2's progress note dated 10/25/24: seen per wound MD with coccyx assessed, bedside debridement performed to promote wound healing, malodor persists. R2' medication administration record and physician orders did not document any new antibiotic treatment after 10/7/24 -10/26/24. R2's braden score dated 9/15/24 documents a score of 13 which indicates moderate risk for skin breakdown. R2's hospital record dated 10/26/24 documents under diagnosis: Sacral osteomyelitis. R2's facility wound assessment reports dated 10/15/24 and 10/22/24 documents under odor: yes, signs of infection present: yes. R2's plan of care initiated 8/19/24 documents: R2 has pressure injury to coccyx, is at risk for delayed wound healing and is at risk for further alteration in skin integrity related to immobility muscle wasting, quadriplegia, R2 has history of sepsis, anxiety asthma, fever, bedbound, wounds present on admission. Varied compliance with repositioning. Limited tissue perfusion at the point of pressure immobility and infrequent offloading. Adult failure to thrive and skin failure. Interventions include: monitor for signs and symptoms of infection (redness, warmth, swelling, pain, excessive drainage, odor) and notify provider. Date Initiated: 08/20/2024 ; Ongoing assessment of wound to evaluate signs of deterioration or improvement and possible change of treatment. Date Initiated: 08/20/2024. Facility policy Physician notification of laboratory/radiology/diagnostic results revised 7/8/24 documents: to assure the physician ordered tests are performed, and to assure test results are reported to the ordering physician so that prompt, appropriate action may be taken if indicated for the residents care. A nurse is responsible for monitoring the receipt of test results. Test results should be reported to the primary care physician or other ordering practitioner. In the event a physician does not respond promptly the alternative physician or medical director will be notified.

Deficiencies at this level require more than one Deficient Practice Statement. A. Based on interview and record review, the facility failed to follow their practice and provide a staff escort to an appointment for a resident R1 diagnosed with dementia, BIMS (Brief Interview for Mental Status) score of 5, identified not capable of unsupervised outside pass privileges. R1 was dropped off by transportation company on 5/8/24 at approximately 2:00pm, unknown drop off point. R1 was later found by family in streets trying to self-propel over a curb ramp approximately 3:30pm. This affects 1 of 1 resident (R1) reviewed for supervision. The Immediate Jeopardy which began on 05/08/2024 when R1 was dropped off at around 2:00pm at an outpatient appointment alone, without a staff escort, and later found in the community approximately 1.5 hours later by his daughter in the streets. V3 (Administrator) was notified of the Immediate Jeopardy on 07/09/2024 at 1:44 pm. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 07/09/24 but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the training. Findings include: R1's face sheet denotes R1 has diagnoses of dementia, unspecified convulsions, anxiety disorder, and history of falls. R1's MDS (Minimum Data Set), dated 3.29.24, section C for cognitive pattern denotes R1's BIMS score of 5 (cognitively impaired), section GG for functional abilities denoted mobility devices wheelchair is checked. R1 community survival skills assessment, dated 3/29/24, denotes the resident is sufficiently alert oriented coherent and knowledgeable allowing him or her to be considered for independent outside past privileges, the box for no is checked. Outcome/ recommendations denotes, the resident does not appear to be capable of unsupervised outside past privileges at this time. R1 most recent care plan, dated 5/24/24 denotes R1 has impaired cognitive function/dementia, or impaired thought process related to dementia. R1 is at risk for falls r/t (related to) decreased mobility, balance, and endurance. Facility incident report, dated 5/8/2024, denotes, incident no injury, during transportation, per resident daughter, resident did not make the appointment and was located outside the hospital and taken with her. Interviewed daughter and inquired of residents' well-being and per daughter resident uninjured. Mental status - orientated to person, orientated to situation. Level of consciousness, alert, mobility- wheelchair bound. Predisposing physiological factors- impaired memory, other. Predisposing situation factors- during transfer. Other behaviors, transport. Resident 73 y/o (year old) AA (African American) male who is alert and oriented to name and situation with confusion related to diagnosis of dementia with behavioral disturbance. PMH (Primary Medical History) includes, HTN (hypertension, HF (Heart failure) ischemic heart disease, HLD (high density lipoprotein), and anxiety. During transport to appointment, resident was not transported to office suite by driver, who cited that resident began to display behaviors on arrival and refused to share paperwork and did not know what suite appointment was located. Per resident daughter, resident did not make the appointment and was located outside the hospital and taken home with her. Investigation and review of facility practice regarding escort appropriateness to ensue. V1 (Unit clerk) statement denotes, 10:00 AM (V12, Transportation Driver) called and asked if he can change R1 appointment time to 1:00 PM so he (V12) has time to get back south in time to pick up his other riders. I (V1) told him yes, if it was okay with the daughter who was meeting him at the appointment. 1:00 PM (V12) called facility to say he was about 20 minutes out. 1:04pm I (V1) called V11 (R1 family) and told her about the new pickup time. She said it was OK because she lives around the corner from there about five minutes away. Daughter stated since he will be there early, she will get him something to eat before he goes to his appointment at 3:45pm. I told her I will call her once the transport actually arrives and leaves our facility. 1:32pm I called (V11) and told her they picked up her dad and he's on his way to the appointment. 3:00 PM (V11, R1's family) called and told me he wasn't there. 3:15pm made my first call to (clinic name). I told them the daughter called and said her father (R1) was not at the appointment. (Medical Insurance company) then made their first attempt to contact the transportation company which I found out is (transportation company name). They were unable to reach them. I was told they were escalating it to the supervisor; I (V1) will get a call back. 3:45 PM I called the doctor's office to see if the patient had checked in, I was told he hadn't. 4:00 PM I called (V11), but I did not receive an answer. I called (clinic name) back and I stayed on the phone for about 45 minutes while the supervisor tried repeatedly to contact the transportation company as well as other supervisors. 4:45 PM I called doctor's office again and was told the office was closed and he had not checked in. 4:55 PM I received a call from the driver (V12) telling me he was on his way to pick up (R1), I explained to him the situation he told me that he dropped the patient off at (outpatient clinic address). That he went to the desk relations and spoke to a man named (name noted) in a red shirt and told he was dropping (R1) off and that his daughter was meeting him there. I stayed on the phone with him while he went in the building spoke to the guest relation person. They went to the 4th floor to see if (R1) or (V11) was there, and they were not. 5:30PM- 6:00 PM (V11) called the building and said she (V11) had (R1). I stayed on the phone with (V12) to see if he needed to go and pick him (R1) up from wherever they were. 6:00 PM I called (V11) to see if she wanted us to pick him up and she did not answer so I left a voicemail. Signed (V1). On 6/28/24 at 10:46 AM, V1 (Unit Clerk) said, (R1) had a scheduled appointment, pick up time was at 2:45pm on 5/8/24. (R1's) appointment was on the 4th floor of the building. (R1) has managed Medicaid and the insurance schedules the residents' transportation. The driver called the facility and asked if he could pick (R1) up early so that his other clients were not late for their appointments. V1 said she got approval from R1 daughter for early pick up. V1 said she called R1 daughter when the driver picked R1 up because the daughter was going to meet R1 at the clinic for his appointment. V1 said she got a call from R1's daughter inquiring about R1 whereabouts because R1 had not made it to the appointment. V1 said she hung up and immediately called the insurance company because the insurance company scheduled R1's transportation. V1 said although the driver contacted her for early pick up, she did not have his contact information. V1 said she was able to contact the insurance company and they were calling the driver. V1 said she stayed on hold while the insurance company tried to contact the driver. V1 said she may have been on hold for more than an hour. V1 said she called R1's daughter back with no response. V1 said V13 (Assistant Director of Nursing) was aware of the situation. V1 said V13 did not give her any directives. V1 said she figured V13 was aware because she was standing around when she was on the phone with the daughter. V1 said around 4:55PM, V12 (Transportation Driver) called her and said he was going to pick R1 up for his scheduled pick up. V1 said that was unusual because the drivers never call and say they are picking up the residents. V1 said at that time she asked V12 where he dropped R1 off too, because R1's daughter said R1 did not make it to his appointment, and she could not find R1. V1 said V12 was not aware R1 did not make it to his appointment. V1 said V12 informed her that he took R1 inside the building and R1 was having behaviors and would not give him (V12) the paperwork to determine where he supposed to go. V1 said the driver did not contact the facility or her to inform them R1 was having behaviors. V1 said the driver should have contacted the facility if R1 was having behaviors and would not give the paperwork to determine R1's drop off location/point/destination. V1 said R1's daughter called her sometime after 5:30PM and stated she found R1. V1 said at that point, management was involved and she doesn't know the details surrounding where R1 was found. V1 said the drive to R1's appointment was about 20-minute drive. V1 said she doesn't know if the driver escorts the residents to the clinic or just to the entry door of the building. V1 said she doesn't know the process. V1 said she doesn't know who should know the process. On 6/28/24 at 12:39 PM, V11 (R1's family) said on 5/8/24 around 9:00 AM, V1 (Unit clerk) called her and confirmed R1's appointment and confirmed she will be meeting R1 at the appointment. V11 said V1 called her back at 11:00AM, and stated the driver will be picking R1 up at 1:00PM instead of 2:45PM because he had multiple clients to pick up and did not want them to be late for their appointments. V11 said she was agreeable. V11 said V1 suggested that she (V11) wait for R1 on the fourth floor where the scheduled appoint was planned. V11 said she arrived at the appointment, and she waited. V11 said time passed and R1 never arrived. V11 said she asked the receptionist if R1 had checked in, and was informed R1 had not checked in. V11 said she waited because she was aware the driver had other clients to drop off and or maybe they were running late. V11 said the appointment time had arrived and R1 was not there. V11 said she went downstairs to look for R1 and she did not see R1. V11 said she called the facility and spoke to V1 to inquire about R1 whereabouts. V11 said V1 informed her R1 was picked up and she would call the insurance company so they could contact the driver. V11 said she went back to the clinic building to look for R1; she did not see R1. V1 said she began to worry, and her nerves were bad because she did not know where her father was. V11 said she got in her car to look for a local convenience store to buy cigarettes to calm her nerves, V11 said there was a lot of traffic, the cars were at a standstill. V11 said as she got closer to the intersection, she saw her father crossing the street in his wheelchair, trying to self-propel over a curb ramp. V11 said the cars was honking their [NAME] for R1 to get out the way. V11 said she immediately got out her car to help R1. V11 said R1 was upset stating the driver just left me. V11 said she called 911 but they never arrived. V11 said she later got a call from the driver stating \he was going to pick R1 up from his appointment. V11 said she informed the driver he will not be picking R1 up because she did not trust R1 in the care of that driver. V11 said she took R1 home. V11 said she was very upset about the situation. V11 said the facility should have sent R1 with a staff escort because R1 has dementia, and R1 could have been hurt. V11 said R1 told her the driver just left him. V11 said she doesn't think the driver took R1 inside the clinic building. V11 said R1 should not be in the community alone, R1 has dementia. R1 could have been hit by a car. On 6/28/24 at 12:11PM, V14 (Insurance company rep) said the transportation drivers do not take clients inside of facilities for scheduled appointments; the drivers do not register clients for their appointments. V14 said the driver can open the door to the clinic if they choose to do so. V14 said the expectation is drop off /pick up only. On 6/28/24 at 1:52PM, V15 (transportation company) said the transportation company provide curb to curb service only, drop off and pick up. V15 said the drivers do not take clients inside of the buildings/ facilities. V15 said it's for insurance purposes. V15 said escorts can accompany the client during the trip. V15 said he recommend clients are escorted during a trip. V15 said V12 is no longer with the company; he is not available for interview. V15 said he doesn't recall the situation with R1. On 6/28/24 at 2:00PM, V4 (Director of Nursing) said she was aware R1 did arrive to his appointment. The facility investigated and concluded (R1) should not have gone to an appointment without a facility staff escort. (R1) has dementia and his community survival assessment show he can not be in the community alone. Due to the incident, the facility has put practices in place. On 7/2/24 at 11:55AM, V13 (ADON- Assistant Director of Nursing) said V1 (unit clerk) did not inform her R1 did not arrive to his appointment; V1 did not inform her R1's daughter called the facility concerned about R1's whereabouts. V13 said she was passing by V1 going to the standdown meeting, and she heard V1 on the phone and made a statement what do you mean you can't find your father. V13 said she did not stop to inquire about what she heard because V1 was on the phone and could have been discussing anything. V13 said R1's situation was not discussed in the standdown meeting. V13 said she was not aware of the situation. V13 said after the meeting, she did her task of ensuring the facility had enough staff on duty because there was a call off. V13 said some time after 5:30PM, she was made aware R1 was found, and that's when she learned R1 did not arrive to his doctor's appointment. V13 said the Director of Nursing was involved at that time. V13 said V1 did not inform her of the situation with R1 missing from his appointment. V13 said V1 should have informed her, the DON, or the charge nurse immediately. V13 said she would have contacted management and initiated the missing resident protocol. V13 said V1 should have not tried to handle that situation by herself. On 7/2/24, V4 (Director of Nursing) said she was made aware of R1 not arriving to his scheduled appointment on 5/8/24 sometime after 5:30PM. V4 said V1 did not notify her when she was initially notified of R1 being missing, and she (V1) should have notified her immediately. On 7/2/24 at 1:34PM, V16 (Licensed Practical Nurse/LPN) said she was R1 nurse on 5/8/24 for the morning shift, and she was not aware R1 did not make it to his appointment and R1 was missing. V16 said she became aware of this today because staff was standing around talking about. On 7/2/24 at 3:51PM, V17 (Registered Nurse) said she was R1 nurse on 5/8/24 for the evening shift. V17 said no one informed her that day R1 did not arrive to his scheduled appointment and R1 was missing. V17 said someone did inform her R1 would not be returning to the facility after his appointment; she documented that. Facility missing resident/elopement policy, with last review date of 11/15/2018, denotes all personnel are responsible for reporting a cognitively impaired resident attempting to leave the premises or suspected of missing to the charge nurse as soon as practical this includes any resident that did not sign out on pass and or did not notify a staff member of his or her leaving. Should an employee discover that a resident is missing from the facility he or she should immediately report the missing resident to the charge nurse or nursing supervisor. Review physician order to determine if the resident is out on an authorized leave or pass. Alert staff by announcing code green over the paging system. Inform staff of the name of the resident and visualize pictures of resident if available. Make a thorough search of the building and the premises. Notify administrator and director of nursing immediately if the resident is not found after the search the administrator and director of nursing will evaluate the situation and develop a plan of action based on the individual resident. The Immediate Jeopardy that began on 05/08/24 was removed on 07/09/24 when the facility took the following actions to remove the immediacy: * R1 returned to the facility by daughter. R1 reassessed without any adverse negative outcome. * R1's appointment has been rescheduled. * All facility contracted Medi-car and ambulance companies were contacted and reviewed facility's expectations during transportation, including ensuring the resident is safely transferred and reported to the receiving appointment staff. Contact was initiated and concluded on 7/9/2024. * All residents with scheduled appointments have the potential to be affected by the alleged deficiency. * The facility has conducted a comprehensive review to identify any other residents with scheduled appointments and has established corresponding staff escorts. Initiated 5/9/2024 and on-going. * The facility has conducted a comprehensive review to identify residents with a BIMS under 11 and those which cannot safely access the community independently, additionally, each resident is reviewed for additional factors such as behaviors, physical challenges and assistive devices as appointments arise to ensure a facility escort is assigned. Initiated 5/9/2024 and is on-going/updated on a weekly basis. * The Unit Clerk will communicate upcoming appointments 72 hours prior to appointment date with confirmed staff escort name to nursing staff during morning meeting utilizing the appointment communication log. Initiated and completed 5/9/2024. * Emergency QA meeting conducted on 7/9/2024 at 4:30pm. * Residents with upcoming scheduled appointments will be evaluated by nursing and social service departments to ensure resident is cognitively appropriate for independent community access. Initiated 5/9/2024 - on-going. * Family members of residents with upcoming scheduled appointments who require an escort, will be contacted to, optionally, assist with escorting/accompanying residents during transport if available. If family is not available, the facility will ensure a staff escort will accompany residents for all non-contracted transportation companies for residents who have been determined to require an escort. Initiated 7/9/2024 - on-going. * The Director of Nursing or designee educated the facility transportation coordinator/unit clerk on communicating upcoming appointments 72 hours prior to appointment date, including the name of the confirmed staff escort communicated to nursing staff during morning meeting utilizing the appointment communication log. Initiated and completed 5/9/2024. * Facility has developed a Transportation Communication Form which is being provided to all transportation companies at the time of scheduled resident appointments, which communicates pertinent transportation information, including resident drop off points, contact information for physician office and facility, to ensure resident safety. 7/9/2024 - on-going. * The Director of Nursing or designee educated the facility staff on the new Transportation Communication Form to be provided to transportation drivers at the time of resident pick-ups for scheduled appointments. 7/9/2024 - on-going. * The Director of Nursing or designee educated the facility staff who may accompany residents on appointments that Escort must call the facility to inform/confirm resident's arrival to appointment location office/Suite with Unit Clerk immediately to verify safe arrival. Knowledge check to be completed with staff escort prior to leaving the facility for verification/clarification. Initiated 7/11/2024 and on-going. * The Director of Nursing or designee educated the facility staff on immediately implementing the missing resident policy and procedure once a resident has been identified as missing. 7/9/2024 - on-going. * Staff, including agency, not present in the facility will be educated prior to starting their next shift. This training will be ongoing for new hires in the orientation process and has been added to the agency staff orientation folder. Initiated 7/9/2024 - on-going. * The Director of Nursing or designee will audit 3 random residents with scheduled appointments twice a week for 3 months or until compliance has been determined thereafter, to ensure safe transport and delivery of cognitively impaired residents to scheduled appointments. Initiated 5/9/2024 - on-going. * The Director of Nursing or designee will audit 3 random staff, twice a week for 3 months, for knowledge checks of previous education related to missing resident policy and Transportation Communication Form to ensure safe transport and delivery of residents who have been determined to require a staff escort to scheduled appointments. Initiated 7/11/2024 - on-going. * Findings of the quality review audits will be brought to the facility QA meeting until such time as the committee has determined substantial compliance has been achieved and recommends ongoing monitoring. Initiated 5/9/2024 - on-going. Completion date of systemic Corrections: 07/11/2024 40066 B. Based on observation, interview, and record review, the facility failed to follow their fall prevention protocols by not completing an accurate fall risk assessment evaluation, failed to implement individualized interventions related to the root cause of falls to minimize the risk, and failed to implement fall prevention interventions. This affected two of three residents reviewed for fall and fall preventions. These failures resulted in R3 falling from a wheelchair with no non-skid pad applied. R3 sustained a laceration to the left eyebrow resulting in sutures. The findings include: 1.R3's diagnoses include, but are not limited to, Epilepsy, Hypertension, Convulsions, and Alcohol Use. R3's cognition is documented on 4/23/24 as severely impaired. R3's physician orders includes orders for daily administration of Escitalopam (antidepressant) and Clonazepam (benzodiazepine). R3's Medication Administration Record documents R3 received the ordered medications on 5/20/24 and 5/25/24. R3's behavior assessment, dated 4/23/24, documents he has no behaviors. Review of R3's falls include falls on 5/20/24 and 5/25/24. R3's notes on his fall report of 5/20/24 documents interventions to minimize the potential for falls non skid pad to his wheelchair. R3's notes on his fall report of 5/25/24 documents interventions includes non skid pad to wheelchair. Fall requires suture repair. R3's care plan denotes 5/23/24 non skid pad to the wheelchair. R3's progress notes, dated 5/25/24, documents R3 returned from emergency room . R3 noted to have seven sutures over his left eyebrow. R3 has steri strip/ wound closures across the bridge of his nose. R3's hospital records, dated 5/25/24, documents R3 presents status post fall complaining of a 2cm laceration to middle of R3's forehead. Upon chart review this is the second fall within the past week as the patient had a fall two days ago when he was seen in the hospital. Face location: Nose Length: 2cm. Steri-strips and sutures (sutures for forehead laceration and strips for nose laceration). Facility Reported Incident report from 5/26/24 documents R3 had a fall and was sent to the emergency department for evaluation and received sutures to left brow area. On 6/28/24 at 12:40PM, V2, Licensed Practical Nurse (LPN) said R3's falls are related to his confusion. V2 said, (R3) had one fall from his wheelchair and the Aide, (V6), was taking (R3) to from the lobby into the dining room. (R3) fell forward. (R3) did not have his feet on the wheelchair pedals or have pedals on his wheelchair. V2 said R3 got sutures on the upper eyelid. V2 said, (V6) said to me, (R3's) feet got stuck. V2 said R3 was not able to pedal himself in the wheelchair before the fall; he was dependent on staff. On 6/28/24 at 1:04PM, V5, Certified Nursing Assistant/CNA, said, (R3) can stand and pivot and he is on fall precautions. (R3) wears hipsters, a helmet, and is kept in common area when he is in his chair. (R3) gets restless and he is alert and confused. (R3's) fall prevention interventions are on the closet door. V5 showed the surveyor the closet with a document that includes hipsters, helmet, keep in common area, and non slip pad for wheelchair. At 1:09 PM, V5 stood R3 up. R3 was sitting on a wheelchair cushion, but no non slip pad on the seat on or under the wheelchair cushion. On 6/28/24 at 1:11PM V6, CNA, said, I was getting (R3) to take him into the dining area from the sitting area. (R3) was sitting in his wheelchair in the sitting area. When I moved (R3), he dropped his feet and fell forward; he hit his head. (R3) was dependent on me to move him in the wheelchair; he could not move it himself. On 6/28/24 at 1:03PM V4, Director of Nursing, said, (R3) had seizures with some of his falls. The next time (R3) fell , he became very confused. I think all of (R3's) falls surround his seizures and dementia. (R3) is not educatable, not redirectable, and we try to protect him from injuring himself. The CNA was pushing (R3) in the wheelchair and he was able to follow commands, but he put his feet down and fell . On 7/2/24 at 12:55PM, V10, Nurse Practitioner, was asked what medications can place residents at risk for falls. V10 replied, Antihypertensives, Narcotics, Benzodiazepines, and Antidepressants. Midodrine can place a resident a risk because of changes in blood pressure. Clonazapam is a Benzodiazepine. Lexapro is an Antidepressants. Both trade names or generics can be a risk. The nurses should know these medications can cause increased risk of falls for the residents. 2.R2's diagnoses include, but are not limited to Atrial Fibrillation, Acute on Chronic Diastolic (Congestive) Heart, Multiple Myeloma Not Having Achieved Remission, Anemia in Chronic Kidney Disease, End Stage Renal Disease, Type 2 Diabetes Mellitus, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5, End Stage Renal, and Moderate Protein Calorie Malnutrition. R2's fall scale evaluation, dated 2/7/22, indicates the resident has never fallen; a score of 51. R2's fall scale evaluation, dated 2/22/24, indicates the resident has never fallen; a score of 26. Low risk is identified as a score of 0-24; moderate risk 25-44; high risk 45 or more. Review of R2's physician orders includes orders for daily administration of Escitalopam (antidepressant) and blood pressure regulating medications (Cardizem, Midodrine, and Metoprolol Tartrate). Review of R2's Medication Administration Record documents R2 received the ordered medications on 2/22/24. Progress Notes written by V8, dated 2/22/24, documents, resident observed on the floor in room in a sitting position. Patient is awake and alert follows direction but could not state how she fell . Appears weak. Fall report, dated 2/22/24, documents R2 on the floor in room in a sitting position. Blood pressure 142/73; heart rate 108; Oxygen saturation 91%; Temperature 101. Weakness was indicated as predisposing factor. Root cause analysis, dated 2/23/24, stated R2 sent to the hospital and will be reviewed upon return. Remind to use her call light, upon return. Progress Notes written by V8, dated 3/19/24, documents, resident observed on the floor in room during nursing rounds by RN. Resident lying on floor in left lateral position. Fall report, dated 3/19/24, written by V8 documents R2 was observed on the floor during nursing rounds. Blood pressure 130/64; heart rate 66; temperature 101.4; oxygen 89% placed on oxygen. Root cause analysis dated 3/20/24 documents following chemotherapy and dialysis R2 has weakness. R2's care plan, initiated on 3/19/24, states call don't fall added on 2/23/24. On 6/28/24, V7, Restorative Nurse, said, For hygiene, toileting, dressing, and transfers, (R2) required 1 person assist. For bed mobility, (R2) was able to complete that with supervision. (R2) was able to participate in her cares. If a resident falls, we might look at root cause analysis. V7 read the root cause documented on R2's fall report, dated 3/19/24. V7 said R2 denied falling, if she fell she could not remember. V7 read the resident received chemotherapy and dialysis. V7 said R2 had been placed in bed immediately after treatment. V7 said, The follow up interventions were draw labs, urine culture, place floor mats, use a low bed, and place the call don't fall sign. (R2) had weakness. V7 said before 3/19/24, R2 had no falls. V7 said, The fall prevention interventions were the basics, keep everything in reach. For safety on everyone we say keep everything in reach, keep call light in reach, falling leaf for high risk. V7 said R2 was not on the falling leaf program. V7 said R2 was not high risk upon admission for falls. V7 said R2 had a fall on 2/22/24. The surveyor asked V7 if R2's fall scale evaluations are accurate. V7 said she can't answer for the nurse completing the evaluation. On 6/28/24 at 3:23PM, V8, Registered Nurse/RN, said, On 3/19/24, (R2) was observed on the floor during rounds. She was status post chemo and had returned to the facility. The last time I saw her, before the fall, she was in the bed. I found (R2) on the floor. Generally, (R2) did not use the call light often. This was (R2's) first fall that I was aware of. After a fall occurs we put new measures in place. On 7/2/24 at 9:54AM, V4, Director of Nursing, said, I was not employed here when (R2) fell on [DATE]. At 10:08AM, V4 said the cause of R2's fall on 2/22/24 was being symptomatic and anemic. V4 said, Symptomatic means (R2) was having shortness of breath, dizziness, and weakness. Specifically (R2) was experiencing weakness and then she received dialysis earlier that day, which caused more weakness. On 7/2/24 at 11:43AM V7, Restorative Nurse, was asked what medications may place R2 at risk for falls. The surveyor presented V7 R2's physician orders. V7 said, I can't answer that, I would have to look them up to know the side effects. The Fall Prevention Program, dated 11/28/12, states, The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Care plan incorporates Identification of all risk issues; addresses each fall; interventions are changed with each fall as appropriated; preventative measures.

Based on interview and record review, the facility failed to perform dressing changes and daily assessments of a wound as ordered for two days, and failed to address a foul odor in the sacral wound for six days. This affected one of three residents (R6) reviewed for pressure sore prevention and treatment. This failure resulted in an abscess/infection forming behind the sacral wound that needed to be surgically drained while hospitalized , and the sacral wound developing a foul odor which was not identified at the facility. Findings Include: R6 is an [AGE] year old with the following diagnosis: urinary tract infection, peripheral vascular disease, hemiplegia of the left and right side following a cerebral infarction, and chronic ischemic heart disease. The Care Plan that is not dated documents R6 has a pressure ulcer at the sacrum that is unstageable related to deconditioned status, impaired mobility, friction/shear risk, and incontinence. Interventions include: evaluate ulcer characteristics, monitor ulcer for signs of progression or declination, and provide wound care per treatment order. The Wound Assessment Details Report, dated 12/12/23, documents the sacral wound is a stage three and measures 1.3 cm x 1.3 cm x 0 cm. It is 100% bright pink or red tissue with no signs of infection. The Wound Physician note, dated 12/19/23, documents the unstageable sacral wound measures 1 cm x 2 cm x 0.1 cm and is considered stable. There are no signs of infection. The Wound Assessment Details Report, dated 1/1/24, documents the sacral wound is now classified as unstageable and is 100% soft necrotic tissue with no signs of infection. It measures 13.5 cm x 9.5 cm x unknown. The Wound Physician note, dated 1/2/24, documents the unstageable wound to the sacrum measures 13.5 cm x 9 cm by unknown and is 10% granulation tissue in 90% eschar. No signs of infection or noted. The Wound Physician note, dated 1/25/24, documents the unstageable sacrum wound measures 10.5 cm 8 cm by unknown and is 25% elation tissue with 75% sloth. There's no signs of infection. The Wound Physician note, dated 1/30/2,4 documents the unstageable wound to the sacrum measures 10.5 cm x 8 cm by unknown and is 25% granulation tissue with 75% slough and no signs of infection. The Wound Assessment Details Report, dated 1/31/24, documents the sacral wound is still in stable and measures 10.5 cm x 8 cm by unknown and is 25% bright pink or red with 75% soft chronic tissue. There is no odor documented. This wound is considered improved on this day. The Wound Physician note, dated 2/6/2024, documents the unstageable sacral wound measures 10.5 cm x 10 cm by unknown indicating the wound grew in size from the last assessment. The healing status is documented as declined. The wound is 25% granulation tissue was 75% eschar. The physician does not document any signs of infection nor a foul odor. There's no documentation that the foul odor was addressed on this day. A Wound Care note, dated 2/6/24, documents plan of care was revised to the left back thigh, sacrum, left outer ankle, and left outer thigh. A Nursing note, dated 2/12/24, documents R6 was picked up via transport and accompanied by a family member to the wound care clinic. Later that evening, a family member called the facility to let them know R6 was being admitted at the hospital for wound debridement. There is no documentation in the nursing notes that a foul odor was identified during rounds with the physician, or when the nurse changed the dressing. The Treatment Administration Record, dated 02/2024, documents there was an order change to the sacral wound on 2/7/24. Dressing changes were not completed on 2/10/24, 2/11/24, and 2/12/24. The Hospital Records, dated 2/12/24, document R6 was sent to the hospital for a wound evaluation of the sacrum. A CT (Computer Tomography) scan showed abscess formation in the gluteal muscles on each side of the sacral wound. It is documented the sacral wound also had a foul odor. The sacral wound was debrided in the operation room, where the abscess were also drained. R6 had a peripherally inserted central catheter (PICC) placed in the left arm for a needed course of six week of IV antibiotics. On 3/27/24 at 11:35AM, V12 (Wound Care Nurse) stated R6's dressing change order was revised to be done daily because that was the family request. V12 reported the sacral wound plateaued and became more necrotic. V2 denied being aware of any signs or symptoms of infection in that wound. V12 stated, If a wound is showing any signs or symptoms of infection, then the physician is notified, and usually the wound is cultured. If there is a bad odor, more drainage, or any other changes that we didn't notice before that are causing a decline, staff should let the physician know. Dressing changes should always be performed as ordered so the wound has the best chance of healing. On 3/27/24 at 3:23PM, V18 (Wound Physician) stated V18 did not remember seeing any signs or symptoms of infection in R6's sacral wound. V18 denied being notified of any changes in the wound. V18 reported, If there are any changes to a wound, then a resident is sent to the hospital for evaluation. Changing the dressing orders to once a day was based off family request. If a resident is having signs of the wound being infected, then it needs to be addressed immediately so it doesn't get worse. On 3/28/24 at 3:28PM, V20 (Nurse) stated floor staff is a responsible for completing dressing changes when wound care nurses are not in the building. V20 remembered the dressing change frequency was revised towards the end of R6's stay at the facility, due to more necrotic tissue. V20 reported the wound was declining, so the physician kept trying different treatment plans. V20 denied any symptoms of infection while taking care of R6. V20 stated signs of infection would be redness, increased drainage, discoloration, or a bad smell. V20 denied remembering R6's sacral wound ever having a foul smell. V20 reported the dressing changes populate on the TAR (Treatment Administration Record), so staff nurses know what to do, and dressing changes should always be completed as ordered. V20 stated if it's not charted TAR then it has to be considered not done. V20 reported any changes to the wound should be discussed with the doctor so everyone can be on the same page. On 3/28/24 at 3:46PM, V21 (Nurse) stated V21 only changed R6's dressing maybe two or three times. V21 denied noticing any signs or symptoms of infection in the sacral wound. V21 reported signs and symptoms of infection could be swelling of the wound, increased drainage, redness, or an odor. V21 stated any changing condition to the wound, then the physician must be notified to see if there are any new orders to follow up. V21 reported treatment order should always be followed in the dressing changes need to be completed on the days they are due. V21 stated If the dressing changes is not charted on the TAR, it means it wasn't done. V21 denied R6 having any signs of infection the last time V21 took care of R6. On 3/29/24 at 11:11AM, V22 (Wound Physician) stated, If a resident has an abscess that is spreading to the gluteal muscles, then they need to undergo debridement at the hospital, likely in the operating room, to make sure everything is cleared out. Abscesses happen when the necrotic material is not eliminated or removed quickly enough, and it spreads to healthier tissue because there is no way for it to drain out. If a resident develops an abscess, staff would see an overall general decline in the appearance of the wound, it would hurt more, and it may or may not have signs of infection. There should be at least something telling you that you have an issue going on behind the wound. V22 reported dressing changes always need to be completed as ordered. V22 stated daily dressing changes are done at wounds that are more concerning and need to be assessed for any changes more frequently. V22 reported, Although there are many factors, an abscess can develop in as soon as 48 hours. On 3/29/24 at 3:55PM, V2 (Director of Nursing/DON) stated dressing changes should always be completed unless a resident refuses. V2 reported this allows staff to assess the wound. V2 stated if the dressing changes aren't being completed as ordered, then the wound is not being assessed properly. The policy titled, Skin Condition Assessment & Monitoring - Pressure and Non Pressure, dated 6/8/18, documents, Purpose: To establish guideline for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries, and other non-pressure skin conditions and assuring interventions are implemented. Wound Assessment/Measurement: . 3. Dressings will be checked daily for placement, cleanliness, and signs and symptoms of infection . 7. Physician ordered treatment shall be initialed by the staff on the electronic Treatment Administration Record after each administration. 8. A licensed nurse shall observe condition of the wound incision daily, or with dressing changes as ordered. Observations such as drainage, dehiscence, redness, swelling, or pain will be documented in the nurse's notes .

Based on interview and record review, the facility failed to develop an effective plan of care to include monitoring to prevent a dementia resident assessed to be at high risk for falls from falling, and failed to ensure facility staff provided safe bed mobility while providing direct resident care. This affected two of three residents (R1, R2) reviewed for fall prevention and safety. This failure resulted in R1 suffering a right sided pelvic fracture, and resulted in R2 sustaining a laceration to the head that needed to be repaired with Dermabond at the hospital. Findings Include: 1. R1 is an [AGE] year old with the following diagnosis: dementia, encephalopathy, weakness, lack of coordination, heart failure, and chronic kidney disease stage 3. R3 is an [AGE] year old with the following diagnosis: type 2 diabetes and chronic obstructive pulmonary disorder. The Minimum Data Set, dated dated [DATE], documents a Brief Interview for Mental Status score at 6 (severe cognitive impairment). The Functional Abilities and Goals, dated 11/14/23, documents R1 is partial/moderate assistance with toileting hygiene. R1 is supervision or touching assistance with bed mobility and sitting on the side of the bed. R1 needs partial/moderate assistance with going from a sitting to a standing position and with transfers. The Care Plan, dated 12/7/22, documents R1 is at high risk for falls. An intervention documented after the fall on 12/2/23 is documented as a call don't fall sign was placed in R1's room. There is no documentation of what kind of monitoring R1 requires. This care plan also documents R1 has impaired cognitive function/dementia or impaired thought process related to dementia. A Nursing note, dated 12/2/23, documents R3 informed the nurse R1 had fallen a couple days ago. R3 observed R1 moaning in pain. Upon assessment, R1 indicated pain around the right hip. An order for an x-ray was given by the physician. The Fall Report, with no date, documents R3 informed the nurse R1 had fallen a couple days ago. R1 was assessed and indicated pain around the right hip area. The physician was notified and placed an order for an x-ray. R1 is alert and oriented to person only. The Post Fall Observation, dated 12/2/23, documents R1 fell in R1's room, but it was unable to be determined what R1 was doing immediately prior to the event. The fall was witnessed by R3. R1 was not able to say what happened. Pain was noted to the right hip. The x-ray report, dated 12/3/23, documents the x-ray of the right hip showed an acute/recent minimally displaced fracture of the right inferior pubic ramus. The Hospital Records, dated 12/2/23, document R1 was sent to the hospital for an evaluation after a pubic ramus fracture was found on an imaging study at the hospital. R1 complained of right thigh pain. R1 is at normal baseline, but pain was noticed while staff was cleaning R1. The x-ray of the right hip showed a possible fracture of the right femoral neck, and a CT (Computer Tomography) scan is recommended for further assessment. This was discussed with the facility. R1 was discharged back to the facility with a recommendation to follow up with ortho. A Serious Injury Incident and Communicable Disease Report, dated 12/11/23, documents R1 had a fall with physical injury. R1 is oriented times one. On 12/2/23 at approximately 8 PM, R3 reported to the CNA R1 had a fall in the bathroom a few days ago. R1 was assessed and complained of pain to the right hip. The physician was notified and gave an order for an x-ray of the pelvis. The x-ray was completed and showed a fractured to the right inferior pubic ramus. A new order was placed by the physician to send out one to the hospital for further evaluation. It was determined R1 uses a wheelchair due to unsteady gate. R1 is impulsive with poor safety awareness. R1 requires partial to moderate assistance with transfers and ADL care. R3 reported that a couple days ago R1 attempted to self ambulate to the bathroom and fell . R1 got up from the floor and ambulated back to the bed. R1 was diagnosed with a pelvic fracture in order to follow up with ortho from the hospital. On 3/19/24 at 1:46PM, R1 was sitting in a wheelchair watching TV in the dining room being monitored by staff. R1 denied any problems in the facility, and denied having any pain. R1 was not able to remember having a fall back in December. R1's mental status was assessed. R1 stated the date was 2006, but R1 was not able to state president or location. R1 denied having broken pelvis. R1 denied needing any help walking and reported getting up alone to walk when R1 needs. On 3/19/24 at 2:49PM, V3 (Nurse) stated R3 reported R1 fell , but reported it days after it happened. V3 reported an x-ray was taken, and showed a fracture so R1 was sent to the hospital. V3 admitted R1 is confused and only alert and oriented times one. V3 stated R1 will try to get up to walk alone without any assistance, but once staff see, they sit R1 back in the wheelchair. V3 reported being unable to speak on monitoring due to not knowing when R1 exactly fell . On 3/19/24 at 3:55PM, V4 (CNA) stated V4 was not aware of any falls R1 had in the past. V4 reported R1 is transferred to the wheelchair, then taken him to the bathroom and transferred to the toilet. V4 stated R1 likely, would not be able to walk to the bathroom alone due to being too weak, and only being able to walk short distances. V4 confirmed R1 was confused and will attempt to get up alone. V4 stated R1 is kept in areas where staff can better to monitor R1 safety. V4 reported if R1 is in R1's room alone, then staff try to monitor R1, but denied any set monitoring schedule. On 3/19/24 at 5:36PM, V8 (Nurse Practitioner) stated R1 had a fall in R1's room, and R3 notified staff leader of what happened. V8 reported the imaging showed fracture to the pelvis, and these type of fracture are usually caused by some kind of impact. On 3/20/24 at 1:35PM, V9 (Restorative Nurse) stated this fall was reported by R3, and had happened a couple days prior to being reported. V9 reported an x-ray was completed of the hip and showed a pelvic fracture. V9 stated R1 was sent to the hospital and returned with in order to see orthopedics. V9 stated R1 needs partial to moderate assist with transfers and toileting, but is supervision only with bed mobility. V9 admitted R1 has an unsteady gate, but is able to walk. V9 reported the root cause of the fall was R1 ambulated to the bathroom alone, and fell . V9 denied R1 being able to tell V9 anything about the fall. V9 stated R1 is currently a high fall risk, and was a high fall risk prior to this fall. V9 reported R1 is a high fall risk because of an unsteady gate, periods of confusion, and gets up without calling for assistance. V9 stated normally residents monitored every two hours but for high fall risk residents staff tries to monitor them every one to two hours. V9 denied having any documentation of where the monitoring is in the computer system, or documenting it as an intervention. V9 stated, We just try to have staff keep an eye on them as they pass the room. On 3/20/24 at 4:02PM, V2 (Director of Nursing/DON) stated, This was not witnessed, and the only way staff was made aware of the fall was by (R3) a couple days later. V2 reported the x-ray showed a fracture to the pelvis. V2 stated a root cause was not able to be determined, because they couldn't even determine if R1 actually fell , but a nurse practitioner did say the fracture was likely due to trauma. V2 admitted R1 will get up without assistance. V2 denied R1 being unsafe. V2 was not able to give an exact timeframe of when high fall risk resident should be monitored, but stated it is more than two hours. On 3/29/24 at 1:39PM, V23 (Primary Physician) stated V23 did not remember this fall, but reported the imaging report showed a fracture to the pelvis. V23 confirmed these type of fractures usually happen from some type of blunt force trauma. V23 said, It could happen from a fall or some other type of injury where the pelvis has some type of impact. The facility tries to give the residence as much autonomy as possible. Without restrictions and residents are allowed to fall, but they should not be getting hurt. This, unfortunately, was a mechanical fall with injury, but we were trying to give the resident as much autonomy as possible. 2. R2 is an [AGE] year old with the following diagnosis: spinal stenosis, weakness, lack of coordination, and lymphedema. The Functional Abilities and Goal Assessment, dated 11/30/23, documents R2 needs substantial/maximal assistance with toileting hygiene. The Care Plan, dated 11/20/22, documents R2 is at high risk for falls related to decreased mobility, balance, and mobility. Interventions were updated on 12/26/23 after the fall, with bilateral fall mats and restorative bed mobility. The Minimum Data Set, dated dated [DATE], documents a Brief Interview for Mental Status score of 11 (moderate cognitive impairment). A Nursing note, dated 12/26/23, documents R2 had a fall and to check the post fall observation form for more information. R2 was sent to the hospital and returned around in stable condition. A Nurse Practitioner note, dated 12/27/23, documents R2 had a fall yesterday with a laceration to the forehead. R2 was sent out to the hospital for evaluation and returned with no acute findings. The Hospital Records, dated 12/26/23, documents R2 presented to the emergency department status post fall. R2 stated falling out of bed while R2 was being changed. R2 had a laceration to the head that was 6 millimeters. The laceration was repaired with dermabond. The Fall Report, dated 12/27/23, documents the nurse was called to the room and was found on the floor with bleeding to the head. R2 was assessed and got back to bed. 911 was called and transferred to the hospital. R2 and the CNA (Certified Nursing Assistant) reported when R2 was rolled on R2's side, R2 slid off the bed striking R2's face on the floor causing a laceration. Bilateral fall mats will be placed while R2 is in bed. The Serious Injury Incident Report, dated 1/2/24, documents R2 fell on [DATE] around 5:00AM by rolling out of bed during morning care. R2 bumped R2's head on the floor causing an opening to the skin on the forehead. On 3/19/24 at 1:37PM, R2 reported having a fall the day after Christmas. R2 stated R2 rolled off the bed while being changed by a CNA, and R2 hit R2's head on the floor. R2 reported R2 was bleeding from the head. R2 stated R2 was sent to the hospital, where a CT scan of the head was completed but was negative. R2 reported needing the laceration to the head glued in order for the bleeding to stop and the wound to be closed. There now is a scar about 1 inch by 0.5 inches in the top, middle of the forehead. R2 stated while being changed by a CNA, R2 was turned too close to the edge and fell off the bed. R2 reported R2 is not able to turn over in bed without assistance due to being weak. R2 stated the CNA then ran out of the room and got a nurse to come help. R2 reported the nurse called 911 and R2 left the facility but returned the same night. R2 reported having a headache and feeling dizzy. On 3/19/24 at 4:07PM, V5 (CNA) stated V5 was getting everything ready to provide morning care to R2, when V5 raised the head of the bed. V5 reported proceeding to roll R2 away from V5 while using the draw sheet. V5 stated, I held (R2) with one hand, and was going to provide pericare with the other hand. As soon as the wipe touched (R2), (R2) jumped and fell off the bed. V5 stated nothing was next to R2's bed at the time of the fall, and R2 had a cut on R2's head that was bleeding. V5 reported R2 needs assistance when turning over in bed and cannot do it alone. V5 stated, I don't know how she didn't know she was too close to the edge. V5 reported attempting to pull R2 back into the bed as R2 was falling, but was unsuccessful. On 3/19/24 at 4:18PM, V6 (Nurse) stated V6 was alerted by V5 that R2 fell from the bed. V6 reported R2 had a laceration to the head. V6 stated calling 911 due to R2's had bleeding. V6 reported V5 told V6 that R2 jumped and rolled out of the bed while V5 was providing care. On 3/20/24 at 1:35PM, V9 (Restorative Nurse) stated, The intervention put in after this fall, was to work with restorative to familiarize (R2) with the boundaries of the bed. V9 confirmed R2 needs partial to moderate assistance when rolling in bed and positioning R2. V9 reported R2 went to the hospital to get a laceration repair. On 3/20/24 at 4:02PM, V2 (DON) stated this fall was witnessed and happened during patient care. V2 reported R2 jumped while V5 was providing incontinence care, and R2 jumped off the bed. V2 stated R2 needs assistance with repositioning in the bed due to not being able to do it alone. V2 reported CNAs we're educated on bed mobility and had to do a return demonstration of how a resident should be positioned during care. On 3/29/24 at 3:29PM, V24 (Primary Physician stated) V24 does remember R2 having a fall where R2 hit R2's head. V24 denied remembering how R2 fell off the bed. V24 reported not being able to remember all detailed about the fall, but stated if R2 was not as close to the edge of the bed, then maybe R2 would not have fallen out. V24 stated, The residents have a right to fall, but we need to try to prevent injuries as much as possible. The policy titled, Fall Prevention Program, dated 11/21/17 documents, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary .In addition to the use of Standard Precautions, the following interventions may be implemented for residents identified at risk: The resident will be checked approximately every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care.

Based on interview and record review, the facility failed to follow their Emergency Care policy and procedure by not immediately calling 911 for residents identified to be in need of emergency medical assistance. This failure applied to two (R9, R12) of two residents reviewed for emergency services, and resulted in R9 noted to be experiencing symptoms of a stroke for over an hour before being transferred to the hospital; R12 experienced acute respiratory distress for over 40 minutes before 911 was called. The Immediate Jeopardy began on 7/4/23 when the facility failed to immediately call 911 for R9, who was experiencing symptoms of a stroke. V1 (Administrator) was notified of the Immediate Jeopardy on 8/31/23 at 11:07AM. The survey team verified by observations, interviews, and record review, that the Immediate Jeopardy was removed on 9/5/23, but noncompliance remains at Level Two because additional time is needed to evaluate the effectiveness of the interventions implemented. Findings include: 1. R9 is identified as a [AGE] year old female who originally admitted to the facility on [DATE], and was discharged on [DATE]. R9 has multiple diagnoses including but not limited to the following: acute embolism, type II DM, hyperlipidemia, CHF, HTN, and CKD. Progress note written by V8 (Licensed Practical Nurse/LPN) reads: 7/4/23 8:47AM - (R9) alert with confusion. Progress note written by V10 (Wound Care Nurse) reads: 7/4/23 12:57PM - (R9) with altered mental status, assessment in progress per assigned nurse. Progress note written by V8 (LPN) reads: 7/4/23 2:27PM - (R9) slow to respond. Hand grasp to right hand strong, left hand grasp absent. Flaccid to left side denies pain. MD (medical doctor) made aware of clinical finding new orders to send to hospital for evaluation. Daughter at bedside, made aware of change of condition. (R9) being transferred to hospital by ambulance service. Per hospital record, dated 7/4/23, R9 was brought to the emergency room due to new aphasia and weakness of the left upper extremity. R9 was diagnosed with having a stroke and left hemiparesis. R9 was a poor candidate for thrombectomy due to poor functional status. Progress note written by V10 (Wound Care Nurse) reads: 7/5/23 7:42AM - (R9) admitted to hospital with a stroke. On 8/21/23 at 3:30PM, V30 (Family Member) said, I would visit (R9) every day while she was at the facility. On 7/3/23 when I saw her, she was perfectly fine. She would typically talk with me, laugh, using her phone, and was very alert and oriented. On 7/4/23 at around 1:45PM, I came in to bring (R9) lunch. When I walked in her room, she was lying in bed, flat on her back, staring at the ceiling. I tried to talk to her, but she would not respond to me. (R17) was her roommate, and she told me she has not spoken or made any noise at all today. I asked (V8, Licensed Practical Nurse/LPN) what was going on with (R9). She told me at this time she believes she has a urinary tract infection (UTI) because she was not responding and seemed very confused. I asked (V8) to call an ambulance and send her to the hospital. (V8) said she would call one, and it would take them around 30 minutes to an hour to arrive. At the hospital they let me know that she had experienced a stroke. She now cannot swallow, has a gastric tube, and is paralyzed on her left side. She is barely communicating and is not as alert and oriented as she was prior to this incident. On 8/22/23 at 10:23AM, V8 (LPN) stated, I was the nurse on duty on 7/4/23 and was assigned to (R9). Prior to this day, (R9) was alert, oriented, and able to converse with others. I saw her in the morning and she was fine. She ate breakfast and I gave her morning medication. Later on that day, I went in her room and she was not recognizing me. She wasn't responding to me, and couldn't tell me my name. She was talking, but was not her normal self. I checked her vitals at this time and they were stable, however, her mental status was not at baseline. At this time, I noted she had weakness to one side, which was new for her. She did not look as if she was in distress, but just having a change in mental status and weakness. That triggered me to call the doctor. When I spoke with the doctor, they told me to send (R9) to the hospital. The family arrived during me attempting to call the doctor, and they were notified of the situation. I called 911 and sent her out to the hospital. Her clinical situation indicated a need to call 911, it was an emergency. I cannot remember who showed up, if it was just the paramedics or the whole 911 team. The fire department is down the street from the facility and arrives typically in a couple minutes. V8 also said V10 (Wound Care Nurse) came into R9's room at some point to provide wound care treatment, and also thought R9 was having a change of condition. V8 was asked how she would respond to or recognize a change of condition. V8 said, I typically will check their vitals to make sure they are stable, their level of consciousness, and will do a full body assessment. I will check their pupils, hand grasp, lung sounds, etc. If I identify that a resident who is normally talking and later they are not aware of anything or saying things they do not normally say; this would trigger me that the resident is having a change of condition. If I note anything that is abnormal, I immediately notify the doctor. From there, depending on the situation, I follow the physician's orders whether it is a new medication, treatments, or to send the resident out to the hospital. If the resident's consciousness, pulse, or oxygen is dropping, we would call 911. If a resident is in a critical condition, you would want to monitor them constantly and call 911. There is no time to wait for an ambulance service. V8 said, Strokes can happen quickly and every minute counts. Private ambulance services are typically called when the resident is stable, and not in distress and are called when it is appropriate to wait 30 minutes to an hour. 8/23/23 at 10:45AM, surveyor contacted local fire department and confirmed no 911 call or response team was dispatched on 7/4/23 to the facility. The fire department is 800 feet away from the facility. Review of ambulance run sheet documents a private ambulance service was called at 2:27PM and arrived at the facility to R9 at 3:00PM. Ambulance runsheet shows that the ambulance was dispatched due to altered mental status and stroke protocol was initiated upon arrival. On 8/22/23 at 3:09PM, V10 (Wound Care Nurse) said, I was familiar with (R9) and provided her with wound care treatment regularly. On 7/4/23, I walked into (R9's) room to provide wound care treatment when I observed her to be laying on her back, eyes wide open, and looking fearful. There was no other staff member in the room prior to me entering the room. She looked as if she wanted to speak but could not talk. This was a change for (R9) since we usually speak every day. I ran down to the nursing station, where (V8) was sitting, to let her know about (R9's) change of condition. (V8) said she was working on it and had already notified the doctor. V10 said, When I saw (R9), I could immediately identify that she was having or experiencing stroke-like symptoms. If I was the nurse on duty that day, I would have notified the doctor and called 911 immediately. V10 was asked why she did not do an assessment of the resident and respond herself, and V10 responded she notified V8, who was the assigned nurse, and had been assured that the situation was being taken care of. On 8/23/23 at 4:00PM, V20 (Medical Director) stated, I was not notified of this incident, and am not sure who (V8) called on this day. (R9) was at an increased risk for stroke due to multiple diagnoses. I would expect the staff to notify the doctor and initiate the orders that the physician orders. If the physician says to send a resident to the hospital, we expect they will be sent out 911, not with a private ambulance service. Treatment window for a stroke is generally four hours. If they are able to be evaluated and are a candidate for certain types of treatment post stroke. The sooner you can treat a resident that is having a stroke, the better the outcome for that resident. 44570 2. R12 was an [AGE] year old male admitted to the facility 4/10/23, with diagnoses that included corrosion of esophagus, Dementia, and Dysphagia. Admission orders included dietary status of NPO (nothing by mouth), and on 4/24/23, an order was placed for oral suctioning every shift and every two hours as needed. According to the Physician's Order Sheet, R12 did not require any oxygen. On 7/30/23, R12 was emergently transferred from the facility to the hospital in acute respiratory distress. V9, LPN (Licensed Practical Nurse), was the nurse on duty and documented while rounding at 11:15AM, R12 was observed having difficulty breathing and difficulty releasing sputum (thick oral secretions). After suctioning R12, V9 took vital signs that included an Oxygen Saturation rate of 76% (on room air) and assessed crackles (abnormal lung sounds) to the left side. V9 applied 2L (Liters) via Nasal Cannula and paged the physician. At 11:54, V9 documented Oxygen Saturation at 88% via 2L Nasal Cannula, repositioned R12 to the left side, and provided oral suction. V9 wrote orders had been received from the doctor (unnamed) to send R12 to the hospital. At 12:02PM, V9 documented that a private ambulance company was called for transport, with an expected arrival time of 30-35 minutes (approximately 12:32-12:40PM). Oxygen Saturation remained at 88% via the Nasal Cannula. At 12:31PM, V9 wrote upon reassessment, R12 was noted to be clammy and sweaty, using all accessory muscles, and Oxygen Saturation had decreased to 33%. V9 activated a Rapid Response and called 911. Fire Department run sheet indicated the facility called at 12:35PM, and Paramedics arrived at 12:38PM, and provided advanced life support to R12. When Paramedics arrived, they found R12 to be responsive to pain, with an oxygen saturation of 78%. They applied a Non Rebreather Oxygen mask at 15L, and after applying the oxygen mask, R12 still exhibited low saturation levels of 88 and 87%. R12 was taken to the ambulance, where he was placed on a CPAP (Continuous Positive Airway Pressure) and transported to the hospital. Paramedics and R12 arrived at the hospital at 1:05PM. Hospital record noted in the emergency room , at 2:34PM, R12 was placed on sedation and mechanically ventilated. R12 was diagnosed with acute hypoxic respiratory failure, aspiration pneumonia, sepsis secondary to aspiration pneumonia, hypoxemia, metabolic encephalopathy, and anemia. On 8/23/23 at 1:21PM, V34, Representative of a private ambulance company, confirmed a call was received from the facility at 12:02PM for R12, who was noted to be in respiratory distress. The ambulance was dispatched at 12:23PM, and arrived at the facility at 12:55PM. On 9/1/23 at 9:46AM, V51, Paramedic, said he was one of the first from the Fire Department to arrive on scene. V51 said, (R12) was on oxygen, (although could not determine how much), and was still displaying substandard oxygen saturations. The team placed (R12) on a non-rebreather mask, which is used to deliver a higher concentration of oxygen, but (R12) continued to saturate in the 70's and 80's. Because of this, the CPAP was administered to provide additional breathing support because the oxygen alone was not an effective measure to increase saturation. V51 said this was implemented quickly, because if left for a prolonged time, lack of oxygen could cause organ system failure. On 8/23/23 at 12:58PM, V35, Medical Doctor for R12, said, I don't have a Nurse Practitioner or a Physician's Assistant, and I don't recall the nursing staff calling me to notify me that (R12) was having respiratory distress symptoms. Optimally an oxygen saturation for a resident without COPD (Chronic Obstructive Pulmonary Disease) should be greater than 90% on room air or oxygen. If (R12) was administered oxygen and it remained below this range, that means he was not getting enough oxygen. Oxygen can be administered via nasal cannula or face mask. Oxygen levels should improve immediately within applying the oxygen, and if it does not improve within 5-10 minutes, 911 should be called. Nurses are allowed to give up to 6L of oxygen via the nasal cannula. With the Non Rebreather mask, you can go up to as much as you can on the oxygen tank- there is no limit to how much oxygen you give a resident who is in need if they are already in respiratory distress. The Nonrebreather Mask would have been a better option if it was available, once it was determined the Nasal Cannula was not getting the resident to the optimal level. On 8/29/23 at 11:13AM, V32, LPN/Nurse Supervisor, said on 7/30/23 she was the supervisor on duty for the morning shift. V32 said she was alerted to R12's condition when V9 called a Rapid Response over the intercom. V32 was not alerted R12 was in respiratory distress prior to the announcement, and said by the time she arrived at the bedside, 911 Paramedics were coming behind her. When V32 said she had worked as an LPN over [AGE] years in the hospital and long term care settings. Later in the interview, when asked about administering oxygen to a resident experiencing respiratory distress, V32 said, I would give 4L of oxygen to see if that helps. Using sound nursing judgement, we can give more than 2L without an initial order because the goal is to help the patient and get them to breathe- which is the priority. If I can't get the oxygen saturation to increase with a nasal cannula, I would place a non-rebreather mask and call 911. The fire department is around the corner and takes like two to three minutes to arrive. I don't know what the situation was before I arrived, so I can't say how long the resident was in distress or if anything else could have been done differently at the time. The nurses know to contact me when they need me. On 8/21/23 at 11:51AM, V49, Family Member, had difficulty communicating during the interview, due to being distressed and sobbing throughout. V4 said, I came to visit (R12) on 7/30/23 and he looked awful! The nurse told me that she had called non-emergency ambulance and that his oxygen levels had ranged from 30-80%. He was sweating and buck eyed. He was left without oxygen and the nurse was doing sternal rubs and suctioning him. She said that the facility didn't have enough staff to suction regularly and that she called the doctor, but he wasn't answering the phone. Eventually she called 911. The ambulance came and they took him to the hospital put him on a ventilator and he never came out. V49 went on to say R12 passed away 8/16/23 due to complications related to lack of oxygen. The facility was unable to provide policies related to oxygen administration and Rapid Response. Facility Procedure titled Emergency Care (no revision date) states in part; Emergency medical care refers to the care given to residents with urgent and critical needs. The circumstances under which the care given may or may not be optimal; whatever facilities are at hand are used in the most effective manner.Principles of Emergency Management: To preserve life To restore the resident to useful living To prevent deterioration before a more definite treatment can be given. o 1. Maintain a patent airway, employing resuscitation measures, if necessary o 4. Assess for chest injuries and airway obstruction o 7. Assess the resident's vital signs, monitor blood pressure, pulse, and respirations at frequent intervals and document o 8. Allay anxiety and keep resident as comfortable as possible o 9. Observe and re-evaluate resident at frequent intervals In the event of emergencies requiring medical support not available in the facility, staff will immediately call 911 for emergency assistance. Facility policy titled Emergency Care states in part but not limited to the following: Emergency medical care refers to the care given to residents with urgent and critical needs. The Immediate Jeopardy that began on 7/4/23 was removed on 9/5/23 when the facility took the following actions to remove the immediacy: 1. Residents R9 and R12 no longer reside within the facility. 2. Performance Improvement Plan initiated, titled: Emergency Care. Initiated 9/1/23. 3. All Nursing staff in-serviced by Director of Nursing on Emergency Care. 4. Medical Director Notified on 8/31/23 at 11:50 AM. 5. The Nurse consultant/Clinical Managers will provide training and in-servicing to all nursing staff on identifying residents with urgent and critical needs and are able to identify when to call 911 to respond to emergency situations. 6. The Nurse consultant/DON will provide in-servicing and training for agency and nursing staff who have not been scheduled to work (PRN staff, vacation, or medical leave). All will be required to complete in-service and training prior to the start of their shift before reporting to their assigned units. 7. The DON/nurse supervisors will provide in-servicing and training for newly hired nursing staff and newly scheduled agency staff assigned to the facility. They will be required to complete in-service and training prior to reporting to their assigned units. 8. Clinical nursing staff and staff members including agency staff will not be permitted to work until they have been in-serviced and trained on Emergency Care immediately. Staff on vacation or on leave will be contacted and educated via telephone with documentation that such education was conducted. 9. An audit was conducted to identify any current residents who have the potential of having a stroke, heart attack or other medical emergency. The care plans of these residents were revised. 10. To ensure compliance, DON will audit/investigate all hospital transfers from 8/31/23 and ongoing to ensure policy and procedure were followed. 11. Findings of the QA (Quality Assurance) audit shall be used to determine the level of compliance. If needed, additional training will be completed immediately and shall be submitted to the QAPI Committee for review and follow-up. 12. An emergency QA meeting was held with the facility Medical Director (via Telephone) on 8/31/2023 at 1:00 pm. Attendees were Elevate Regional Nurse Consultant, facility Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Practitioner to review abatement plan and plan of correction. 13. Facility Medical Director to conduct an in-service to clinical staff on Emergency Care. 14. QA committee will review this plan of correction until such time consistent substantial compliance has been met as determined by the QA committee. Audit findings will be discussed by the QA committee and monitoring will be adjusted as determined by the QA committee.

Based on interview and record review, the facility failed to keep residents free from injury, who were assessed to be a fall risk and require staff assistance for ADLs (activities of daily living). These failures applied to four of four (R1, R3, R7, and R12) residents reviewed for falls and resulted in R1 sustaining a laceration to her forehead after a fall; R3 sustaining a subdural hematoma after a fall; R7 sustaining a left hip fracture which required surgical intervention after a fall; and R12 sustaining abrasions to the scalp and ear as a result of a fall. Findings include: 1. R7 is a [AGE] year-old female admitted to the facility on [DATE], with medical history of Cerebral atherosclerosis, chronic kidney disease, anemia, type 2 diabetes, Alzheimer's disease, vascular dementia, pulmonary hypertension, and hyperlipidemia. Fall risk assessment, dated 2/16/2023, coded R7 as a high fall risk. Minimum data set assessment (MDS), dated [DATE] coded R7 as requiring extensive assistance with one staff physical assist for all ADLs (Activities of Daily Living) including bed mobility and transfer. R7 was described as confused and wanders into other residents' rooms. Facility reportable, dated 4/9/2023, states, Resident presented with increased confusion, wandering, resident ambulating down the hall, went into the room and fell . Resident was sent to the hospital, was diagnosed with left hip fracture, and underwent ORIF (Open Reduction Internal Fixation). Hospital record, dated 4/9/2023, stated R7 sustained a commuted intertrochanteric fracture involving the proximal left femur, and underwent a surgical procedure described as intramedullary nailing and reduction of intertrochanteric femur fracture. On 8/29/2023 at 12:09PM, V11 (Licensed Practical Nurse/LPN) stated (R7) is a high fall risk. The day (R7) fell , I came to work in the morning and while conducting my rounds, resident was not in her room or dining room. I located the resident in the north hall sitting on a couch by herself, and asked her if she want breakfast and she said yes. V11 brought the resident back to the dining room, sat her on a regular chair, went to resident's room to get her wheelchair, and transferred resident from the regular chair to wheelchair. V11 said eventually, she saw the resident walking down the hallway; It was lunch time, and the CNAs (Certified Nursing Assistants) were in the dining room passing trays; they should have seen the resident leave the dining room. V11 said that she tried to redirect R7, but R7 was swinging her hand and yelling to be left alone, saying that she wanted to go home. V11 said at this point, she left R7 alone because she did not want to get hit, and R7 continued to walk down the hall. V11 went back to passing her medication. A CNA who was not assigned to R7 was making rounds, and found R7 on the floor in another resident's room. V11 was asked about leaving R7 alone to walk down the hall, and V11 stated, Looking at it now, I don't think that was the best decision; I probably could have called the CNA or another staff or put the resident in a wheelchair. (R7) is a fall risk, wanders into other resident's room and is at risk of injuring herself while wandering. 2. R1 is a [AGE] year-old female who was originally admitted to the facility on [DATE], with history of Alzheimer's disease, dementia with other behavioral disturbance, unspecified fall, essential primary hypertension, low back pain, hyperlipidemia, weakness, unspecified lack of coordination, dysphagia oral phase, other abnormalities of gait and mobility, etc. On 8/24/2023 at 9:58AM, R1 was observed in the dining room, alert and awake with confusion; resident was in a wheelchair and unable to answer any questions. Review of R1's medical record indicated resident is dependent on staff for all activities of daily living. R1's Minimum Data Set Assessment, dated 4/13/2023, coded R1 as requiring extensive assistance with two persons physical assist for bed mobility and transfer, dressing, toilet use, and extensive assistance with one-person physical assist for eating and personal hygiene. Facility reportable, dated 7/3/2023, documented staff took R1 to room to assist with pm ADLs. Staff observed resident attempting to self-transfer from chair to bed. As staff prepared to put resident in bed, resident fell forward striking her head on the floor causing a laceration to the forehead. On 8/29/2023 at 3:06PM, V33 (CNA) said after dinner, she was working with another CNA, but V33 was rolling R1 to her room when she fell face forward; the other CNA was behind her, she was just coming to help her put resident in bed. Immediately after her statement, V33 then changed her account, and then stated R1 was by the bed and the wheelchair was locked; R1 just leaned forward and fell while V33 was standing right there, but could not catch R1. V33 added she has taken care of R1 before; she is two persons assist for transfer and total care for ADLs; she is not able to lift herself up from a chair. V33 stated they normally use gait belt for transfer, but she did not have any that day because the facility does not have any gait belts at this time; they were told they are on order. V33 stated resident did not have a footrest on her wheelchair though she is not able to propel herself. On 8/29/2023 at 1:21PM, V32 (LPN) said V33 (CNA) told her they were pushing the resident to the room, she fell face forward and hit her head from the bed rail; the two CNAs were doing their set together. R1 had a laceration on her forehead and was transferred to the hospital for evaluation. On 8/30/2023 at 12:22PM, V2 (Director of Nursing/DON) said, (R1's) injury happened during transfer; staff were attempting to put (R1) in bed, when she fell face forward and struck her forehead. V2 added the resident cannot self-transfer, and staff were not expecting her to self-transfer; the staff were not close enough to stop her from falling. Per V2, one staff was getting supplies from the drawer, while the other one was just standing there, but not close to the resident. 40718 3. R3 is an [AGE] year-old female with a diagnoses history of Atrial Fibrillation, Adult Failure to Thrive, Dementia without Behavioral Disturbance, Weakness, Lack of Coordination, and Abnormalities of Gait and Mobility, who was admitted to the facility 10/01/2022. R3's current care plan, initiated 10/18/2022, documents the resident has a behavior problem; has dementia---and has behavior of reporting falls, however patient is not able to get up by herself with interventions including Anticipate and meet the resident's needs; R3's current care plan, initiated 12/01/2022, documents she is at risk for falls. R3's Quarterly Minimum Data Set Assessment, dated 04/02/2023, documents she requires extensive one person assistance for transfers. R3's progress note, dated 04/30/2023 07:48 AM created by V42 (Registered Nurse), documents, Assigned CNA (Certified Nursing Assistant) reported to this (writer) that while transferring resident from bed to wheelchair, resident started sliding and she lowered her to the floor. On entering the room, observed resident sitting down on the floor with her back against the bed, upon assessment, noted a bump on resident's right side of forehead, assigned CNA stated that when she returned back to the room, she found resident laying down on the floor with her head against the dresser. No change from patient's baseline, patient complains of pain, as needed pain pill given, called physician, physician gave order to send patient out to (local) hospital emergency room for head CT (Computed tomography) and further evaluation; at 1:28 PM writer followed up with (hospital) emergency room at this time and spoke with staff with admitting diagnosis Subdural hematoma. R3's Hospital Report, dated 05/04/2023, documents she presented to the hospital emergency room for evaluation of a head injury on the morning of 4/30/2023; per emergency medical service she was getting dressed with family/staff and started to lose her balance and hit the right side of her head on the dresser; clinical impression includes traumatic subdural hemorrhage; she was admitted for right scalp hematoma and subdural hematoma. R3's fall incident report, dated 05/08/2023, documents, Assigned CNA (Certified Nursing Assistant) reported to this (writer) that while transferring resident from bed to wheelchair, resident started sliding and she lowered her to the floor. On entering the room, observed resident sitting down on the floor with her back against the bed, upon assessment, noted a bump on resident's right side of forehead, assigned CNA stated that when she returned back to the room, she found resident laying down on the floor with her head against the dresser. R3's fall investigation report, dated 05/08/2023, documents on 04/30/2023, while being transferred from bed to wheelchair, R3 was lowered to the floor in her room. R3 lost her sitting balance striking the right side of head on the nightstand. Injuries include a hematoma. CNA (Certified Nursing Assistant) attempted to transfer R3 from bed to wheelchair. During transfer R3 began to slide and CNA lowered her to a sitting position. While in a sitting position the resident lost her sitting balance, fell over striking her head on the nightstand. R3 was assessed and her physician gave an order to send her to (local) hospital for further medical evaluation. R3 admitted to hospital with a diagnosis of acute sub-[NAME] hematoma. On 08/30/2023 from 11:25 AM - 12:30 PM, V2 (Director of Nursing) stated, If a resident is not at their baseline, or has a change of condition during a transfer, they could experience a fall. (R3) was able to hold herself up in a sitting position. The facility wants to maintain safety for all residents, but to say that no resident would sustain an injury is unrealistic. There was nothing the assigned Certified Nursing Assistant could have done to intervene when (R3) began to slump over and hit her head on the nightstand. V2 stated when a resident is lowered to the floor, they should be monitored overall. V2 stated if you observe a resident to slowly fall over or change position you should intervene, however, if they fall over quickly, there's nothing that can be done. V2 stated R3 was very close to the nightstand when she hit her head. On 08/30/2023 at 1:51 PM V21 (Licensed Practical Nurse) stated R3 uses a wheelchair with trunk control and is able to stand and pivot to some degree. V21 stated R3 is able to sit in her wheelchair without leaning, slouching, or sliding. V21 stated a change of plan or any change in her condition could affect her trunk control. V21 stated R3 also has diagnoses of lack of coordination and weakness. On 08/30/2023 at 2:07 PM, V2 (Director of Nursing) stated, After a resident is lowered to the floor to a seated position nursing staff should hold on to them and call for help unless the resident has good trunk control which would only require staff stay near them. On 08/30/2023 at 3:15 PM, V2 (Director of Nursing) stated R3's investigation report included what was reported to her by V42 (Registered Nurse) and V46 (Certified Nursing Assistant) at the time of her investigation. V2 stated she could not explain the discrepancy between what was originally documented by V42 (Registered Nurse) of the assigned Certified Nursing Assistant finding R3 on lying on the floor with her head against the nightstand upon returning to the room, and what was reported to her during the investigation of the assigned Certified Nursing Assistant observing R3 to slump over and hit her head on the nightstand, after lowering her to a seated position. On 08/30/2023 at 4:07 PM, V42 (Registered Nurse) stated, If a resident needs to be lowered to the floor during a transfer, staff should hold on to the resident and call for help. V42 stated when she arrived to R3's room to examine her after being lowered to the floor by staff during a transfer, R3 was already laying on the floor, with her head right next to the nightstand. V42 stated the information she documented in R3's progress notes regarding the Certified Nursing Assistant finding R3 on lying on the floor with her head against the nightstand upon returning to the room, was what the assigned CNA reported to her, and is likely what happened. 44570 4. R12 was an [AGE] year old male admitted to the facility 4/10/23, with diagnoses that included corrosion of esophagus, Dementia, and Dysphagia. R12 was hospitalized on [DATE] and did not return to the facility. R12's MDS (Minimum Data Sheet), dated 4/24/23, included assessments that indicated R12 required extensive assistance with mobilizing on and off the unit, used a wheelchair for mobility and needed staff assistance with all activities of daily living. According to nurse progress notes, R12 had two falls; one on 4/19/23 without injury, and one on 5/29/23. According to investigation report, V13, LPN, wrote he was alerted to the dining room by staff, where R12 was on the dining room floor. The report noted R12 stated he was attempting to lay down on the couch in the dining room. It was also noted R12 was alert and oriented to person and situation, the fall was not witnessed, and furthermore, R12 sustained an abrasion to the top of scalp and skin tear to the left ear. On 8/31/23 at 11:49AM, V13 said when he was alerted to R12 being on the floor, he confirmed from staff that found R12 there were no other staff monitoring the dining room. V13 said there were other residents in the dining room, and there should have been a staff member present, which could have prevented the fall or injury. V13 confirmed the injuries R12 sustained did not require hospitalization . The Facility's Fall Prevention Program reviewed 08/30/2023 states: Purpose is to Assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The Fall Prevention Program includes: Use and implementation of professional standards of practice. Facility fall policy, revised 11/21/2017, states as its purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Under standards, the policy states in part: A Fall Risk Assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines. Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet. Transfer conveyances shall be used to transfer residents in accordance with the plan.

Based on observation, interview, and record review, the facility failed to ensure a resident was transferred in a manner to prevent injury for 1 of 3 residents reviewed for falls in the sample of 13. This failure resulted in R2 sustaining a laceration requiring sutures. The findings include: R2's Minimum Data Set, dated dated [DATE], shows R2 is cognitively intact and requires two person extensive assistance for transfers. R2's Care Plan, dated 12/19/22, shows (R2) requires extensive staff assist with transfers .Transfers: mechanical lift. The facility's Final Incident Report to IDPH, dated 3/10/23, shows on 3/3/23, (R2) bumped her leg on the wheelchair .laceration to right leg sent to the ER .returned from the hospital with 8 sutures to the right leg. R2's Progress Note, dated 3/3/23 at 11:46 AM, shows laceration observed to right lateral calf during transfer to wheelchair, are noted with adipose tissue present with laceration 2.6 cm x 4.0 cm x 2.2 cm with serosanguineous drainage present; area cleansed with normal saline, pat dry, applied 6 steri-strips wand cover with dry dressing prior to transfer to ER. R2's Progress Note, dated 3/3/23 at 9:36 PM, shows patient received alert and oriented times three. Right lower extremity (RLE) has 8 nylon sutures. There is a small amount of serosanguineous drainage on the dressing, x-ray of RLE negative. Patient given tetanus-diphtheria vaccine in ER. On 3/24/23 at 10:00 AM, R2's right lower leg, just below the knee, contained a healing laceration with steri strips about two inches in length. R2 stated, She was helping me into the wheelchair, there was a gizmo sticking out that cut my leg and kept cutting me as I sat down. It was about two inches. I got 8 stitches. It was something that was sticking out on the wheelchair, I'm not sure what it was but it hurt! I went out to the hospital and got stitches. They usually use the mechanical lift. I'm unable to stand, my legs give out. That time she didn't, we were in a hurry. They should use the mechanical lift, I don't want anyone to get hurt. On 3/24/23 at 10:10 AM, V5, Certified Nursing Assistant (CNA), stated (R2) transfers with a mechanical lift and two people. I transferred her from the bed to the wheelchair by myself with a turn and pivot. When she sat down something caught her leg and cut her. I'm not sure what it was, something sticking out of the area where the leg rest goes. I reported it right away to the nurse, she was bleeding a lot. She got sent out to the hospital. (R2) is supposed to be a two person, mechanical lift. It was my mistake, I got a suspension for it. On 3/24/23 at 12:11 PM, V8, Unit Manager, said R2 was transferred from the bed to the wheelchair, and her leg caught on the brake of the wheelchair and cut it. V8 said R2 is supposed to be a mechanical lift transfer and the CNA transferred R2 by herself. On 3/24/23 at 11:40 AM, V6, Therapy Director, said if a resident is care planned as a mechanical lift for transfers, staff should transfer the resident accordingly. V6 said based on assessment by therapy, the care plan shows the safest method to transfer the resident. The facility's Transfers-Manual Gait Belt and Mechanical Lifts Policy dated 1-19-18 shows In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents mechanical lifting devices shall be used for any resident needing a two person assist.

Based on interview and record review, the facility failed to immediately provide prophylactic antibiotic treatment for a resident after identifying signs of an infection on [DATE] around a resident's dialysis site, the facility failed to start a resident's antibiotic treatment after a physician order was made [DATE] and failed to notify the nephrologist (kidney/dialysis) physician of the onset of signs of an infection near or involving a resident's dialysis site for one sample resident (R9), who received dialysis treatments. As a result, R9 had a change in condition by indication of abnormal vitals on [DATE] and was sent to the local hospital and treated for sepsis after becoming unresponsive at the facility. Findings Include: R9 is a year old with the following diagnosis: hypotension, end stage renal disease, and dependence on renal dialysis. R9 admitted to the facility on [DATE] and discharged on [DATE]. A Wound Care note dated [DATE] documents a post readmission skin assessment was performed. A right upper outer arm abscess was noted draining small purulence (pus like drainage). Wound cultures were obtained, and a dry dressing was applied. The medical nurse practitioner and the wound physician were notified. A Nursing note dated [DATE] documents R9 did not get dialysis today. The nurse practitioner reported to monitor R9 closely and send out to the hospital for any signs of shortness of breath, congestion, or edema. R9 remained stable throughout the shift. Vital signs remain within normal limits. A Wound Care note dated [DATE] documents the wound nurse called the lab for wound culture results, but they are still pending. R9 was seen by the wound physician and a new order of oral antibiotics were ordered. A consult with infectious disease was also ordered. The on-call infectious disease was called, but the consult request was relayed to the answering service operator. A Nursing note dated [DATE] at 6 PM documents the oral antibiotics were not given at this time as scheduled due to being on order. A Nursing note dated [DATE] documents during bedside report R9 was observed not responding and vital signs were abnormal. R9 was lethargic and making abnormal high-pitched noises. 911 was called and R9 was sent to the hospital. The hospital was called to check on the status of R9. R9 was admitted to hospital with a diagnosis of cerebrovascular accident, sepsis, and hypotension. The Hospital Records dated [DATE] document R9 came into the emergency roiagnom on [DATE] at 8:36 AM with altered mental status after being found unresponsive. R9's pupil is non-reactive on the right side and on the left side, the eye has left gaze deviation. R9 is not following commands. The vital signs are as follows: temperature of 99.5 F, pulse of 99 beats per minute, respiratory rate of 30 breaths per minute, and a blood pressure of ,d+[DATE]. There is a concern for sepsis with the fever, the elevated respiratory rate, and low blood pressure. R9 was immediately started on IV (intravenous) antibiotics. The clinical impression in the emergency department is encephalopathy, hypotension, sepsis, due to unspecified organism, and end-stage renal disease on dialysis. R9 was admitted to the intensive care unit. An MRI of the brain was completed and showed concerns for septic emboli and cerebral abscess. Neurological recovery is poor considering R9 has multiple chronic medical comorbidities. R9 is a very poor surgical candidate. The family indicated comfort measures going forward. R9 expired on [DATE]. On [DATE] at 3:46PM, V8 (Wound Care Coordinator) stated, The drainage was noticed on ,d+[DATE]. It was more like a purulent drainage. That means it's more pus like. It looked like an abscess. I notified the wound doctor and the nurse practitioner of what I saw. I got a one culture that day ([DATE]). The wound doctor saw him on ,d+[DATE] and ordered an oral antibiotic. I know the preliminary report for the wound culture came back on ,d+[DATE] in the final on ,d+[DATE]. I know the antibiotics were ordered on ,d+[DATE]. I don't know why there was nothing ordered on the 15th. Maybe the doctor was waiting for the wound culture. I only notify the doctor and then I follow whatever orders they give me and I did not get any. On [DATE] at 11:31AM, V10 (Nurse Practitioner) stated, V8 did send me a text on ,d+[DATE] letting me know that V8 collected a culture because the wound was having some drainage. I know V8 said V8 also let the wound doctor know as well. The wound doctor is responsible for managing the wound. I usually go off the recommendations of infectious disease on when to start antibiotics. On [DATE] at 12:12PM, V11 (Nurse) stated, I checked R9's vital signs when I did R9's assessment around midnight and they were OK. I went in to check on R9 a little later to see how R9 was doing just after 4 AM and R9 started to look a little weak. I went in again around 5 to check on R9 again and R9 wasn't making sense when I was talking to R9. R9 was also quieter. I called 911 around 6 or 6:30 to get him sent out. R9 did begin moaning, and R9's vital signs were off. I know R9's heart rate was elevated, the respiratory rate was elevated, and the blood pressure was elevated. The only thing I got in report that night was to call the pharmacy to check on the antibiotics because they were ordered and R9 still did not get any that day. I did call pharmacy and they said that they were delivering the antibiotics with the delivery that morning. R9 did not take any dose because R9 was gone by the time they arrived. On [DATE] at 2:02PM, V13 (Wound Physician) stated, I saw R9 on ,d+[DATE] and started with Keflex (antibiotic) orally, twice a day, and I also ordered an ID (infectious disease) consult. I know the one nurse got a wound culture as well. I believe I was notified that this happened on ,d+[DATE] when I was rounding. I was not notified before from my recollection. I don't know what the delay was to start the antibiotics. I will have to look into that. Normally the protocol is to identify the drainage and get the culture and then start the prophylactic antibiotics while waiting for the culture. I know R9 went out to the hospital on ,d+[DATE] before the results of the culture came back. I don't know why the antibiotics weren't started on the 18th when they were ordered. If you end up waiting to start antibiotics the wound and the condition of the patient could get worse. The reason you order prophylactic antibiotics is to help reduce inflammatory response. This will help decrease any swelling, warmth, redness at the site. Overall, it will address superficial inflammation, or what we would consider cellulitis. Antibiotics should be started as soon as a change is noticed then you wait the ,d+[DATE] hours for the culture. It should not be left untreated, because the infection will get worse, larger in size, and could cause the stomach symptoms like fever. On [DATE] at 11:31PM, V14 (Nephrologist) stated, I absolutely should've been notified about the drainage coming from the wound around the fistula. I have no memory of anyone telling me that he had any drainage or issues with the fistula. I would have gotten a culture of the area and be very fast to start 1g of Vancomycin (IV antibiotic). This is a very broad-spectrum antibiotic that covers everything. This also lasts in a resident with dialysis for about 72 hours while waiting for the results of cultures. If they're not give any antibiotics, then they can deteriorate very quickly. Sometimes it can happen as soon as 24 hours where they need to be hospitalized . I would have given the antibiotic straight through the fistula area which would've been considered an IV route. I would not have even bothered with starting oral. I would have started the IV antibiotic immediately after the culture was sent, I would not have waited to start any antibiotics and I would have not done the oral either. The Skin and Wound Evaluation dated [DATE] documents an abscess was found to the upper right arm that was present on readmission. It measures 0.7 cm x 1.4 cm x 0.7 cm. There is evidence of infection as increase drainage and warmth are present. It is documented that the drainage is a small amount of seropurulent drainage, which is a milky, pus like drainage that can be a sign of early infection. The wound physician was notified of this wound. The wound culture that was ordered on [DATE] is documented as being collected on [DATE] at 9:16 AM. The lab received this specimen on [DATE] at 9:17 AM. The report was finalized on [DATE] at 8:17 AM. The drainage coming from the right upper arm abscess is documented as being positive for methicillin resistant staphylococcus aureus (MRSA). MRSA is a bacterium that is resistant to certain antibiotics. The Physician Order Sheet (POS) dated [DATE] documents a right upper arm wound culture for purulent drainage and dressing changes were ordered on [DATE]. This POS also documents an order for an Infectious Disease consult to the right upper extremity abscess was ordered on [DATE]. An oral antibiotic was ordered to be given twice a day for the right arm abscess for 10 days on [DATE]. The Medication Administration Record dated ,d+[DATE] documents the oral antibiotic that was ordered on [DATE] was not in the facility when the first dose was supposed to be given at 6 PM on [DATE]. R9 did not receive any doses of the oral antibiotic before being sent to the hospital on [DATE].

Based on interview and record review, the facility failed to ensure one resident (R1),who is a fall risk and known to be compulsive, was supervised appropriately while sitting at the side of the bed to prevent R1 from falling. This failure resulted in R1 falling onto her wheelchair, being sent to the hospital, and sustaining two skin tears to her arms, and a face injury requiring suturing. Findings include: Review of R1's face sheet documents a [AGE] year old female with diagnoses including: Dementia, Cerebral Atherosclerosis, Major depressive Disorder, Anemia, Anxiety, Lack of coordination, history of falling, Cognitive communication deficit, Weakness, Metabolic encephalopathy, Schizoaffective disorder and Essential hypertension. R1's MDS (Minimum Data Set) section G, dated 10/13/2022, documents R1 requires one person physical assist with Activities of Daily Living (ADL), and documents R1 is not steady, and only able to stabilize with staff assistance at all times during moving from a seated to standing position, moving on and off the toilet, and surface-to-surface transfer (transfer between bed and chair or wheelchair). R1's Post Fall evaluation, dated 8/28/2022, documents the following: R1 with a fall risk score of 5. Total score of 5 or above is High Risk. R1's fall risk evaluation, dated 6/6/2022, documents R1's Fall Risk Score as 16. R1's fall risk evaluation, dated 10/6/2022, document's R1's fall risk score as 16. R1's ADL care plan documents the following: Bed Mobility: Physical Assist extensive assist X1. Dated 7/11/2019 Dressing: (extensive assist). Dated 7/11/2019 Toileting: Resident requires physical assistance with clothing and wiping. Dated 7/11/2019 Transfers: Resident requires physical assistance (extensive assist X1). Dated 7/4/2019 Review of R1's fall risk care plan is absent of a new intervention after the 11/23/2022 fall and before the 12/5/2022 fall. Review of R1's fall incident reports document the following: *6/28/2022 - Conclusion: R1 tried to self-transfer and due to leg weakness she fell . Another dated the same day states: R1 slip to the floor trying to self-transfer. *10/6/2022- resident found on the floor by CNA with right side of face above eyelid swelling and skin loss noted with scant amount of bleeding. Conclusion: resident slid to the floor while trying to self-transfer from old wheelchair to new one. *11/23/2022 - Resident observed standing up from wheel chair attempting to transfer and fell on the floor. Conclusion IDT met on 12/1/22 about recent fall without injury. Resident has history of Dementia, Cognitive communication Deficit and Weakness. Resident has history of multiple falls due to patient misconception of abilities to self-transfer, self -toilet, and etc. without assistance from staff. Multiple attempts to educate and redirect resident unsuccessful. Resident receiving hospice services. Medical doctor and family aware of no new orders. New interventions for resident to use call light prior to attempts to self-transfer and encourage seated in dining room for socialization. *12/5/2022- CNA present at bedside, R1 slipped off side of the bed, striking head on wheel chair near bedside, causing laceration to left eye. Conclusion: IDT met 12/5/22 regarding recent fall. Resident was receiving care from the CNA, seated on side of the bed and slid off the side of the bed striking head on the wheelchair. Resident is impulsive with diagnosis of Dementia, Anxiety and Cognitive Communication Deficit with history of falls. Upon statement and interviews, resident most likely fell due to awakening from a dream with disorientation of body placement while in bed. R1's Post fall report, dated 12/5/2022, documents a 2 new wounds one to the right elbow and one to the left hand. R1's skin and wound evaluation, dated 12/5/12, documents 2 skin tears: Right inner forearm measuring 5.0 cm length X 1.4 cm width and the left inner forearm skin tear measuring 2.9 cm Length x 1.9 cm width. Hospital records, dated 12/5/2022, documents the following: R1 presented to the emergency room after a fall with laceration to her face that was cleaned and repaired with 1 suture. Per EMS, the facility staff noted that R1 was being transferred from the bed to the wheelchair when she fell and hit her head on the wheelchair. The facility's incident report documents the following: On 12/5/22 at approximately 5:30 AM, R1 fell off the bed, striking the left side of her face on the wheelchair, sustaining a laceration to the left eyebrow. Resident was sent to (local hospital) and sustained a laceration to left eyebrow with 2 sutures. On 12/23/2022 at 1:21 PM, V15 (CNA) stated she went into R1's room to get her up for the morning at about 5:00 AM to go to the T.V. room. V15 stated she sat R1 on the side of the bed like normal, and she turned around to grab R1's shirt off the bed-side table, which was on the left of V15, and when she looked back at R1, her head was on the side of the wheelchair on the right wheel ( if you are sitting in the chair). V15 stated she did not see the resident fall onto the wheelchair. V15 stated R1 does not walk, and needs help with transfers and all of her ADLS. V15 stated normally if the resident is tired, she would keep an eye on her to keep her from falling. V15 stated she does not know how R1 got skin tears to her bilateral arms. V15 stated she noticed the skin tear after they had got R1 into bed and told the nurse, V18 (Licensed Practical Nurse/LPN), about the wounds. V15 stated, V18 (LPN) and another CNA helped her get R1 back into the bed. R1's nurse's note by V18 (LPN), dated 12/5/2022 at 5:30 AM, documents the following: at 5:30 AM the CNA informed the nurse that the patient had fallen off the bed and hit her head on the wheelchair. Patient slow to respond to name/small laceration on left brow. Skin tear on right arm and left wrist. Patient has altered mental status 911 call. On 12/25/2022 at 3:58 PM, V18 (LPN) states on 12/5/2022, V15 (CNA) came to V18 and said she had R1 sitting on the side of the bed about to be transferred to the wheelchair. V18 stated, In the process of getting R1 dressed, V15 stated she turned her back to get a shirt for R1, and when she turned back around the resident was falling. V18 stated V15 said she grabbed R1 arms to keep her from falling, and R1 fell anyway. V18 stated V15 said R1 fell forward at an angle. V18 stated V15 came and got her, and they went to the room, and the resident was already in the wheelchair. V18 stated V15 got R1 up into the wheelchair. V18 stated R1 was very small and weighed about 90lbs, so it would not have been hard to get her into the wheelchair alone. V18 stated she did physical exam and found skin tears, and small cut to her eye brow, and then the whole area turned red the next day. V18 stated R1's skin tears to her arms probably happened when V15 grabbed R1's arms to try to keep her from falling. V18 stated R1 wasn't responding appropriately during the assessment. V18 stated she believed R1 was confused from the fall. V18 stated R1 was a fall risk, and has tried to get up without assistance previously. V18 stated considering R1 was a fall risk and impulsive at times, it was not appropriate for V15 to take her eyes off of R1 or turn her back to R1 while R1 was sitting at the side of the bed. On 12/22/2022 at 1:26 PM, V2 (Director of Nursing/DON) stated the CNA was getting the resident dressed to get her up. V2 stated the CNA sat R1 on the side of the bed as she always does and turned around to get a shirt and when she turned back around, R1 fell forward and hit the wheelchair that was in front of her. V2 stated the CNA said she yelled for the nurse, and nurse came in, and her and nurse assisted R1 off the chair and into bed. V2 states R1 was one assist at that time. On 12/23/2022 at 2:58 PM, V2 (DON) stated she expect the staff will follow the plan of care when caring for residents. V2 stated R1 was a fall risk and would try to transfer independently. On 12/27/2022 at 2:25 PM, V1, Administrator, stated in an emailed letter the following: the incident with (R1) occurring on 12/5/2022 is a fall that occurred while the resident was getting dressed with a nurse aide present. The resident attempted to get up, stumbled and hit her head on a wheelchair. The CNA turned away from the resident to get a shirt. On 12/23/2022 at 3:30 PM, V16 (Advanced Practice Nurse/APN) stated when she cared for R1, R1 was very anxious. V16 stated, If the staff is sitting the resident at the bedside, the resident is knowing that her next move is to go into the chair. V16 stated staff should not be walking away from the resident when the resident is at the side of the bed. V16 stated, If staff is helping someone with ADLs who is a fall risk, the expectation is to keep the resident safe and free from falling while they are helping the resident. The facility's fall evaluation Safety Guidelines, dated 11/28/2017, documents the following: the intent of the guideline is to ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process: I. identification of hazards and risks, II Evaluation, III. Implementation, IV. Monitoring and V. Analysis.

Based on interview and record review, the facility failed to follow their policy Fall Evaluation Safety Guidelines by not implementing individualized interventions for a high risk resident to prevent or reduce the risk of falling. This affected 1 of 3 residents (R3) reviewed for fall preventions. This failure resulted in R3 sustaining a forehead laceration than needed to be repaired at the hospital after a fall. Findings Include: R3 is a [AGE] year old with the following diagnosis: altered mental status, dementia, unsteadiness on feet, and heart failure. R3 was admitted to the facility on [DATE] and discharged on [DATE]. The Fall Risk Evaluation, dated 9/29/22, documents a score of a 12, which is considered to be a high risk for falls. The fall risk factors are documented as R3 having generalized weakness and limited/poor mobility, having dizziness or [CONDITION(S)], having confusion/disorientation/impulsivity, and having symptomatic depression. R3's Care Plan, dated 9/30/22, documents R3 is at risk for falls. R3 had a fall on 10/2/22, and was sent to the ER (emergency room ) for evaluation. The following interventions are documented on 9/30/22: ensure footwear fits properly, monitor pain in alleviate using non-pharmacological interventions in medication has ordered, ensure the resident's call it is within reach, and encourage the resident to use it for assistance as needed, the resident needs prompt response to our request for assistance, and physical therapy to evaluate and treat as ordered or as needed. There are no interventions related to R1's confusion or lack of safety awareness. R3's Physical Therapy Evaluation, dated 9/30/22, was reviewed. R3 was referred to physical therapy due to an exacerbation of decrease in functional mobility, reduced balance, falls/fall risk, functional limitation with ambulation, and increase need for assistance from others. R3 was admitted to the hospital due to altered mental status and increase confusion. R3 needs supervision or contact guard assist with transfers and walking. R3 has impaired strength in the right and left lower extremity. R3's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score as 14 (cognitively intact). Section G is the MDS documents R3 needs supervision with a one person physical assist for walking in room and corridor. R3 needs a limited one person physical assist with transfers. R3 is not steady and is only able to stabilize with staff assistance. The Fall Incident Report, dated 10/2/22, documents R3 had a fall in R3's room when ambulating that was not witnessed. R3 was oriented times 1 prior to and after the fall. R3 stated, I fell getting out of bed and hit my head on the floor. A Nursing note, dated 10/2/22, documents R3 was found on the floor by V15 (Activity Aide) at 8AM. V15 notified V14 (Nurse). Upon assessment, R3 was sitting on the floor at the foot of the bed. R3 stated, I fell get out of bed and hit my head on the floor. R3 was transferred to the hospital for further evaluation. R3 was admitted to the hospital later that day with a diagnosis of congestive heart failure and forehead laceration. The Hospital Records, dated 10/2/22, document R3 presented to the emergency department for evaluation status post fall. R3 is alert oriented times 1 at baseline. R3 was found on the ground. R1 has a 1 cm forehead laceration that was repaired with tissue adhesive. On 11/12/22 at 3:59PM, V11 (Therapy Director) stated, I did an evaluation on (R3) on 9/30. (R3's) main presentation was due to altered mental status and confusion. (R3) had modest amounts of confusion. (R3) could have a conversation with you, but the details were not accurate. (R3) needed a contact guard to minimal assist with transfers and walking. (R3) did have confusion so she was a high fall risk. (R3) should not have been walking independently by any means. All our concerns and assessments are discussed with the nurse. On 11/12/22 at 4:23PM, V13 (Minimum Data Set/MDS Nurse) stated, Before we go up and assess the resident, we review their medical record. After that, we do our own assessment and then start to go through the care plan. The admitting nurse will start the care plan and then we will elaborate in the care plan on any areas that are triggered. I will also talk with physical therapy to see what they can and cannot do. Most of my information comes from CNA (Certified Nursing Assistant) and nurse documentation. I code them based on what the RN (Registered Nurse) and the CNA have documented. I never saw (R3) get up or move around. Section G in (R3's) MDS (Minimum Data Set) was only based on other staff documentation. When the nurses admit the resident, they do a fall risk evaluation, and if they are at risk for falls, that is always put in the care plan. (R3) was only with us 3 days so I could not get a proper assessment on (R3) to determine if there is any other factors that would've caused any falls. I did not put in any more interventions. On 11/12/22 at 4:29PM, V14 (Nurse) stated, I did my rounds right after report, and I saw that (R3's) head was by the foot of the bed, but (R3) was still laying down. (R3) seemed like (R3) was sleeping. The Activity Aide was walking into rooms, passing out newspapers, and she came to get me to tell me she fell . (R3) was bleeding from (R3's) head a little bit and had a scrape on her head. (R3) was on blood thinners so I knew I had to send (R3) out to the hospital. (R3) was not a high fall risk that I was aware of. I watch new patients for 72 hours to see what they can do. I never got in report that (R3) was a high fall risk. When I went down there, (R3) was trying to say that (R3) was getting up to go home. (R3) was very disoriented, but that was (R3's) baseline. (R3)had no real fall precautions except the bed in the low position and call light within reach. I know they usually will put mats down if someone is a high fall risk. I know (R3) was admitted (to the facility) for confusion, but I don't know what else (R3) was admitted for . (R3's) room was one of the last rooms at the end of the hall. (R3's) call light was not on; (R3) would have been too confused to use it. On 11/13/22 at 9:48AM, V15 (Activity Aide) stated, I was doing my morning rounds passing out newspapers. I was coming out of one room and I saw (R3) on the floor from across the hall. (R3) told me that (R3) was trying to go home. I don't know if (R3) was a high fall risk. That was my first time seeing (R3). (R3's) room was almost at the end of the hall. (R3) had a little bit of blood coming from (R3's) head with a bump. I went to go get the nurse right away and the nurse assessed (R3). (R3) did seem a little confused, but I don't know what (R3) was like normally. I don't know what (R3's) fall precautions were. On 11/14/22 at 12:49PM, V17 (ADON) stated, I know (R3) was found on the floor by staff. (R3) told the staff member that (R3) was trying to go home and when (R3) got up, (R3) fell down. (R3) was alert and oriented times 2 with confusion. (R3) was a high fall risk due to poor mobility, confusion, disorientation, and impulsiveness. This is based off the fall risk assessment. The admitting nurse and the MDS nurse do the care plan with interventions. (R3's) interventions were making sure (R3) had good footwear, monitoring pain, call light and belongings within reach, and physical therapy to eval and treat. When a resident is admitted , the admitting nurse should look at the hospital records to see exactly what the resident was being treated for so we can have a better picture of what to do for them, especially with falls. If the report from the hospital has anything concerning about the specific reasons on why they are falling, then we will put that in the interventions. We did not have any interventions around her confusion. The staff will give off and report to each other who is a high fall risk. On 11/15/22 at 12:11PM, V2 (Director of Nursing/DON) stated, I know the admitting nurse will start to put in interventions when they are admitted and the MDS nurse will finish the rest after their assessment. Usually they just put in basic interventions until they're done with their assessment. Even then the interventions will still be pretty basic because until they actually have a fall; we don't put any specific interventions in because they have to be appropriate for the incident that occurred. I don't remember why (R3) fell , but I think she reported she was trying to leave. (R3) was alert and oriented times two but (R3) did have cognitive issues. On 11/16/22 at 2:43PM, V21 (Nurse Practitioner) stated, I only saw this resident (R3) one time. I did interview (R3) and I would say (R3) is alert and oriented times two. (R3) knew (R3's) name and date of birth, but was confused on where (R3) was at. (R3) thought (R3) was in a hotel. Yes, I would say anyone with confusion is a high fall risk. They are more at risk when they are confused because they may not be oriented to their environment. This is why they need increased rounding for confused residents. It's always best to have interventions in place before a fall occurs to try to prevent an injury as best as possible. The policy titled, Fall Evaluation Safety Guideline,, dated 11/28/17, documents, Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer to treatment appropriately and develop an organization wide ownership for fall prevention to: to achieve each residents maximum potential of physical functioning, to prevent or reduce injuries related to falls, to enhance resident dignity and self-worth, and to rehabilitate residents to their fullest potential of function . facility staff across all departments together with the resident representatives and residents provide resourceful information with individualizing care in approaches. Understanding contributing and predicting factors that will present will assist the determining individualize care approaches . Guideline: Residents who are evaluated as being at risk for falls will be identified and individualized fall precautions will be developed for each resident. Preventative measures shall be taken to decrease the number of falls whenever possible .Procedure: .8. All residents identified as at risk for falls will be reviewed for individualized interventions.

Based on interview and record review, the facility failed to report R4's poor oral intake for 24 days, and failed to implement further interventions to prevent weight loss and dehydration. This affected 1 of 3 (R4) residents reviewed for unplanned weight loss and dehydration. This failure resulted in R4 having a significant weight loss of 9.8% in 10 days, and resulted in R4 needing to be hospitalized for an acute kidney injury due to being severely dehydrated. Findings Include: R4 is a [AGE] year old with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was admitted to the facility on [DATE]. The Admission Hospital Records, dated [DATE], documents R4 was admitted to the hospital from home for feeling dizzy and having a 20 pound weight loss over the past six months. R4 reported not feeling like eating. R4 was in acute renal failure with a BUN (Blood Urea Nitrogen) of 45 and a creatinine of 3.2. R4 reported not having an appetite for the past month. The Dietitian reported believing R4 is not eating due to weakness. The acute kidney injury resolved during the hospitalization with hydration. R4 was sent to a skilled facility for rehab. A Nursing note, dated [DATE], documents R4 was admitted from the hospital. R4 does not have any nutritional risk factors. The Hydration Evaluation, dated [DATE], documents the score as a four. Any score 14 or higher indicates the resident is at risk for dehydration. It is documented R4 has no risk factors for becoming dehydrated. R4 has a documented weight on [DATE] of 137.5 pounds taken via a mechanical lift. The next weight taken was on [DATE], and R4 weighed 124 pounds. The weight was taken also via the mechanical lift. R4 lost 13.5 pounds in 10 days. This was a 9.8% change from the previous weight. The Laboratory Report, dated [DATE], documents R4 had normal sodium, potassium, blood urea nitrogen, and creatinine levels. Normal sodium is ,d+[DATE] mEq/L, normal potassium is 3.,d+[DATE].1 mEq/L, normal blood urea nitrogen is ,d+[DATE] mg/dl, and normal creatinine is 0.,d+[DATE].4 mg/dl. The Laboratory Report, dated [DATE], documents R4 had an elevated sodium level of 149 mEq/L, an elevated blood urea nitrogen level of 76 mg/dl, and an elevated creatinine level of 2.6 mg/dl. There is no documentation that any interventions were implemented at this time. The Laboratory Report, dated [DATE], documents an elevated sodium level of 155 MEQ/L, an elevated potassium level of 5.3 mEq/L, a critically elevated blood urea nitrogen level of 102 mg/dL, and an elevated creatinine level of 3.6 mg/dl. The Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score as 12 (moderate cognitive impairment). Section K of MDS documents R4 has a loss of liquids/solids from the mouth when eating or drinking. It is also documented R4 does not have a weight loss of 5% or more in the past month or 10% or more in the last six months. A Nurse Practitioner note, dated [DATE], documents R4 presented to the hospital on [DATE] with poor appetite, history of falls, dizziness, and 20 pound weight loss in 6 months. A Nursing note, dated [DATE], documents R4 is alert and oriented times 1 - 2. R4 requires a set up assistance with meal times. The Comprehensive Nutrition Assessment, dated [DATE], documents R4 is on a regular general diet within liquids. R4 needs supervision when eating it is currently eating 26 - 50% of meals. R4's general appearance is described as thin, muscle and fat wasting. R4 is documented as having moderate fat and muscle loss. R4's ideal body weight is 154 pounds. It is documented that it is unknown whether R4 had a significant weight loss in the past month, 3 months, or 6 months. The physician was not consulted for weight loss. R4 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Oral intake is variable and at times in adequate to meet nutritional needs with or for eating less than 50% of meals. R4 received a medication which may increase the oral intake. The house supplement was added to increase calories and protein needs. This supplement should be taken twice a day. Staff should monitor weight, labs and oral intake. A Nursing note, dated [DATE], documents R4 refused to eat dinner despite several attempts. The Documentation Survey Report for [DATE] - [DATE] documents R4 needs set up of only or one person physical assist when eating. The percentage of food eaten for R4 is variable each day. For breakfast, R4 ate 0 - 25% for 10 meals, 26 - 50% for 7 meals, 51% - 75% for 1 meal, and 76 - 100% for 3 meals. For lunch, R4 ate 0 - 25% for 10 meals, 26 - 50% for 5 meals, 51% - 75% for 1 meal, and 76 - 100% for 5 meals. For dinner, R4 ate 0 to 25% for 2 meals, 26 - 50% for 2 meals, 51 - 75% for 16 meals, and 76 - 100% for 4 meals. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There is also an order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was placed on [DATE]. There was an order placed on [DATE] for a medication that stimulates appetite. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no other documentation of weights. On [DATE], it is documented R4 was not available. On [DATE], it was documented as not applicable. There are no care plans in relation to weight loss prevention or dehydration prevention for R4. A Nurse Practitioner note, dated [DATE] at 3:44 PM, documents R4 has been eating less than 25% of meals served for a couple days now. R4 is alert and oriented times 2. Plan to get laboratory work and a swallow eval. Continue appetite stimulant medication. A Nursing note, dated [DATE] at 10:48 PM, documents the primary physician came in to review the previous lab results. R4 was examined and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Will recheck labs after the 2L are infused. A Nursing note, dated [DATE], documents R4 is resting in bed with the 1st bag of IV fluid running at the rate ordered. Critical labs were relayed to the physician this morning. A Nursing note, dated [DATE] at 11:20 AM, documents R4 is in bed awake with IV fluid infusing as ordered. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's oxygen saturations were at 86% of 3 L via nasal cannula. An order was placed to transfer R4 to the hospital. 911 was called. A Nurse Practitioner note, dated [DATE] at 4:12 PM, documents R4 has a history of adult failure to thrive it is receiving IV fluids for hypercalcemia and declining kidney function. R4 has had 1.5 L of fluid with no urinary output. The brief is dry. A urinary catheter was inserted with 75 mL of urinary output. The chest x-ray showed right side of pneumonia so IV antibiotics were ordered. R4 begin to saturate in the 80s despite supplemental oxygen administration. R4 does not respond verbally to questions asked. R4 was sent to the ER for further evaluation. A Nursing note, dated [DATE] at 10:20 PM, documents R4 was admitted to the hospital for alert mental status change and [CONDITION(S)]. The Hospital Records, dated [DATE], document R4 presented to the emergency room for altered mental status. R4 is relatively nonverbal and history is limited. R4 is thin appearing with dry mucous membranes. Screening labs are concerning for dehydration. The kidney function labs are the blood urea nitrogen and creatinine. The blood urea nitrogen level four or four is 98 mg/dL and the creatinine level is 3.67 mg/dL. R4 is also in acute on chronic kidney disease. R4 was given 1 L IV fluid bolus. IV fluids were started at 125 mL after the bolus per nephrology recommendations. R4 had elevated troponins which may be secondary to kidney failure. The electrocardiogram was nonischemic. R4 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 ended up developing acute hypoxic respiratory failure and was intubated on [DATE] due to septic shock from right lower lobe aspiration pneumonia. R4 continued to decompensate while in the intensive care unit developing worsening shock, worsening hypoxemia, [CONDITION(S)], and [CONDITION(S)]. R4 was made a do not resuscitate by family. R4 expired on [DATE]. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There is also an order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was placed on [DATE]. There was an order placed on [DATE] for a medication that stimulates appetite. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no other documentation of weights. On [DATE], it is documented R4 was not available. On [DATE], it was documented as not applicable. On [DATE] at 3:31PM, V10 (Nurse) stated, I did send (R4) out to the hospital for mental status changes. (R4's) appetite was very, very poor. (R4) did require you to set up the tray and (R4) needed constant reminders to eat. (R4) would just refuse to eat. (R4) had a medication to help his appetite, but that even didn't help. (R4) had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I was never told that (R4) lost weight when (R4) transferred up to the third-floor. Restorative CNAs (Certified Nursing Assistants) will do the weight and report it to the restorative nurse or management. It was never brought to my attention that (R4) had lost that much weight. I'm only seeing now in the computer for the first time. If they're not drinking much, then you try to encourage more fluids. If they still aren't drinking, then you will call the doctor or nurse practitioner and they will normally get labs. I know because (R4) was not drinking. (R4) needed IV fluids. When a resident has weight loss, the Dietitian will evaluate the patient and the nurse practitioner should know because they will also help put in orders to prevent weight loss. Normally (R4) was verbally responsive; by the end of the day, (R4) was getting worse. (R4) became verbally unresponsive and was not eating at all. The IV fluids were started the day before. The last week or two I took care of (R4), (R4) was only eating maybe 10 to 25% of meals. I don't know how much (R4) was drinking. After about a week of not eating well, then I would let the doctor know. On [DATE] at 4:07PM, V12 (Nurse) stated, If (R4) came in with failure to thrive, then we would monitor eating at meal times. We would also make sure we are taking down his likes or dislikes to see if there was anything else we could give him that he would enjoy eating. Usually when a resident is not eating well, the house supplement is the first to always be given. We also will add on a high calorie shake. If there is a couple days where the resident is not eating well, then we will let the nurse practitioner know. If (R4) came in with poor eating and it's already started while R4's there, it's probably going to continue, so you need to let someone know. The resident isn't going to just decide to start eating. Every time we go into the room we try to encourage them to take a drink. If they are not drinking well or are having less urinary output, then the nurse practitioner should be notified within a day or two. Signs of dehydration would be lethargy, confusion, and dry mouth. You don't want to wait on telling the nurse practitioner or doctor if they aren't drinking because if you had the ability to rehydrate them in the facility, it's better to do that they are than a hospital. On [DATE] at 3:33PM, V14 (Restorative Aide) stated, When a resident is a new admit, I get their weight and their height. Usually it's monthly after that unless there is a doctor order for more. If a resident has a significant weight loss, then I have to report it to the DON (Director of Nursing). It will usually tell me once I put the weight in the computer if it was a significant weight loss. It will give me a percentage of weight that was lost, and if it was significant or not. I don't remember (R4) having any significant weight loss. I know (R4) did have some weight loss, but it wasn't significant. I can't remember exactly what it was but if it was significant, then I would've told someone. The CNAs said that (R4) was just a slow eater and (R4) never really wanted to eat too much. The only thing that (R4) was at risk for weight loss was because (R4) didn't eat much. I don't know what interventions they put in for (R4) for weight loss. If any new interventions are put in, then I will look at the Kardex to see what was put in place. On [DATE] at 12:11PM, V2 (DON) stated, Yes, (R4) was a high risk for losing weight. (R4) came to us for a lack of appetite and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (R4) did have poor PO intake, which was what (R4) was admitted with. The Dietitian did see (R4) on ,d+[DATE]. (R4) was weighed that day and had some weight loss, so the Dietitian added a supplement twice a day. (R4) was never weighed again after that. Usually residents are weighed monthly, and (R4) was already weighed twice that month. I don't believe there is any orders for (R4) to be weighed more frequently. The CNAs document the amount of food that is eaten with each meal. If a resident eats less than 50%, they should report that to the nurse and to me. (R4) could eat with set up help only, but (R4) did need encouraging. A couple days before (R4) left, (R4) did have labs due to mental status change, and we gave (R4) some IV fluids before (R4) was sent out. (R4) didn't respond to the IV fluids, so we had to send (R4) out. I know they repeated the labs after the IV fluids, and the BUN and creatinine were elevated even more. On [DATE] at 1:26PM, V19 (Nurse Practitioner) stated, I know (R4) went to the hospital this time from home, and when (R4) came to us at the end of September, (R4) only weighed 137 lbs. That was a significant weight loss that (R4) had from the previous admission. (R4) weighed over 200 pounds when (R4) was previously admitted to the facility in 2015. I know there was a Dietitian consult for (R4), and the house supplement was added to help with weight gain or maintaining (R4's) weight. We added that on because two weeks after (R4) had come to the facility, (R4) had lost weight. (R4) went from 137 pounds to 124 pounds; that would be considered a significant weight loss. Staff never told me that (R4) was not eating well. I did not find that out until a couple days before (R4) went out to the hospital. We ended up doing labs on (R4) when I found this out, and (R4's) BUN and creatinine were elevated. There was an order to start IV fluids. We did give (R4) almost 2 bags of IV fluids, and (R4) still had not had any output (urine). I went and I checked (R4's) brief, and (R4's) brief was bone dry. We inserted a urinary catheter to see if we could get any output and to monitor it, but barely anything come out. I believe it was under 100 ML. We drew labs again, and the BUN and creatinine did not go down. (R4) then began desaturating, so I sent (R4) out to the hospital for an evaluation. I gave (R4) IV fluids to try to help (R4's) kidneys recover, but (R4) started to develop pneumonia as well, so that was not something we could manage and facility any longer. If a resident is not eating well or drinking well, I tell the staff after two consecutive meals to let me know so we can avoid dehydration. If I was notified before that (R4) was not eating, we could have sent (R4) out in a better condition, or we could have managed better in house and (R4) might not have even need to go out. On [DATE] at 2:23PM, V20 (Dietitian) stated, I did a full assessment on (R4) a couple weeks after (R4) came to the facility. That day I started (R4) on a house supplement that provides extra calories and protein for a resident. I ordered 60 ML of that twice a day. (R4) was also taking [MEDICATION(S)] which is an appetite stimulant. That was ordered on ,d+[DATE]. I also ordered a swallow evaluation, but I was talking with speech, and that came back with no issues. (R4) came to us with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I was notified of the weight loss for (R4), which is why I assessed (R4). There are no further weights after the 10th, so I'll have no further adjustments. If (R4) were to lose more weight and it would've been documented, then I would have probably made more adjustments to prevent that. (R4) just needed encouragement eating. (R4) would just let the tray sit in front of (R4). I know at times (R4) was still refusing to eat even with staff encouragement. (R4) was ill appearing when I saw (R4). (R4) had a moderate amount of muscle and fat wasting. That is where you are supposed to see muscle is that a normal healthy person you would not see it on him. Specifically around his temporal area you could see more bone. Residents that are at risk of losing weight or they have had a significant weight loss weight are usually done weekly. I'm not sure why more weights weren't taken it after the 10th. I know there were moments where (R4) was eating about 50% of (R4's) meals, but a lot of other times (R4) was eating only a couple bites to about 25% of the meal. I am in the facilities monthly to review resident weights. If no weight loss is brought to my attention and no weights are taken then I would not know if a resident needs more interventions added. The policy titled, Hydration Management, dated [DATE] documents, Purpose: To provide each resident with sufficient fluid to maintain proper hydration. Guideline: The elderly have a diminished sense of thirst and decreased kidney function. The amount of fluid needed to maintain health and prevent dehydration is specific to each resident and may fluctuate as resident conditions fluctuate. Therefore, healthcare staff will ensure adequate fluid intake by: licensed staff observation of hydration status every shift during meals, medication pass, and other staff/resident interactions, keeping food accessible, and cueing to drink with meals and medications and assisting and/or cueing drinking as needed. Interventions: may include one or more of the following based on clinical observation: . Develop a care plan based on evaluations and when possible, specify fluid preferences . evaluation by a dietitian, intake and output monitoring to evaluate as determined by the interdisciplinary team. Fluid monitoring: Fluid monitoring should be considered when an evaluation of the following is identified, ordered fluid restrictions or other instances in which fluid volume may potentially be affected: acute changes in condition or illness in which 25% or less of meal intake is consumed, conditions which result in excessive sweating or fever, vomiting, nausea or diarrhea, or involuntary weight loss . Nurses will monitor the total intake each shift and communicate during shift change report the resident intake and progress towards the goal. The night shift charge nurse will calculate the previous 24 hour total by running the intake and output report at the end of each shift and pass along to the oncoming dayshift charge nurse. The dayshift charge nurse will follow up with the assessment and the physician notification unless medically necessary to address sooner. The unit manager will review the total intake and discuss at morning meeting with the IDT to ensure all follow-up assessments are completed. Any trends in deficiencies of fluid that need requirement will be discussed and further assessment/monitoring, residents/families and doctor consultation shall be completed. The policy titled, Nutritional Status Management, dated [DATE] documents, Purpose: It is the practice, in accordance with advanced directives to provide interventions to maintain, improve and respond to nutritional needs. Measures will be taken to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range electrolyte balances, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. The facility will both evaluate and record meal and take a document within the medical record. The interdisciplinary team together with the resident and/or resident representative will identify, evaluate risk factors, and individualized interventions to meet the nutritional needs of the resident and determine through monitoring of health status effectiveness . Guideline: .6. Development and implementation of individualized interventions based on interdisciplinary valuations, resident and/or resident representative goals to promote the highest level of function and dignity which may include but not limited to: encourage consumption of food and fluids during meals, . offer and encourage fluids with meals, medication passes, snacks and while awake, monitor meal consumption, lab values, determination of more frequent weight monitoring, nutritional supplementation, additional fluids, enhanced foods, liberalize diet, finger foods, restorative program, and additional non-food fluid items. 7. Dietitian consultation should follow a trend indicating a 5% weight gain or loss, modify with the interdisciplinary team including the resident and resident representative the plan of care with interventions to address risk factors and restore desired weight goals, and monitor the effectiveness of the modified care plan. 8. Care planning: must address the extent possible, identified causes of impaired nutritional status, reflect the resident's personal goals, preferences and identify specific interventions, time frames and parameters for monitoring. There should be a documented clinical basis for any conclusion that nutritional status or significant weight change are unlikely to stabilize or improve (e.g. physicians documentation to why weight loss is medically unavoidable) and the resident and/or resident representative involvement to ensure goals and preferences. Examples of goals include: a target weight range, desired fluid intake, the management of underlying medical conditions, and the prevention of unintended weight loss or gain . monitoring: interviewing, observing, reviewing specific factors, and evaluating.

Based on observation, interview, and record review, this facility failed to follow its mechanical lift device protocol when transferring one resident (R5) from bed to wheelchair out of three residents reviewed for mechanical lift device required for residents totally dependent on staff for safe transfers. This failure resulted in R5 sustaining lumbar spine transverse process fractures at L3, L4, and L5. Findings include: Review of R5's medical record notes R5 was admitted to this facility on 2/5/2022, with diagnoses including: displaced fracture left patella (knee) with knee immobilizer in place, [CONDITION(S)] ([CONDITION(S)]), diabetes. heart failure, high blood pressure, unsteadiness on feet, and weakness. Review of R5's BIMS (Brief Interview of Mental Status) score is 14 out of 15. Review of R5's ADL (activities of daily living) care plan notes for transfers R5 is total dependence, requires mechanical lift device. Review of R5's hospital record, dated 2/10/2022, notes R5 presented to the emergency room with complaints of lower back pain following fall. R5 stated R5 was on a mechanical lift device when R5 fell down on his tailbone. R5 stated R5 was unable to complete [CONDITION(S)] treatment on 2/10 due to lower back pain. CT (computerized tomography) scan of lumbar vertebrae noted left spinous process fractures at L3 (3rd lumbar vertebrae), L4, and L5. Review of R5's hospital discharge instructions, dated 2/10/22, notes bones of the spine (vertebrae) have portions that extend off to either side of the spine. These portions of bone are called transverse processes. A transverse process fracture which is also called a rotation spine fracture is a break in a transverse process. This kind of fracture results from a sudden and severe bending of the spine to one side. On 3/24/2022, this surveyor observed the mechanical lift device on the nursing unit. The lift device has signage affixed near the controls for the lift device noting: Caution lift patient ONLY with lifter legs in wide position to prevent chance of tipping. On 3/25/2022 at 9:30am, V5, CNA (Certified Nursing Assistant) stated on 2/7/22, V5 assisted another CNA with transferring R5 from bed to wheelchair using a mechanical lift device. V5 stated the lift device started tipping over once they removed R5 from bed. V5 stated V5 tried to prevent R5 from falling by attempting to catch the lift device, but when V5 was unable to keep lift device upright, both CNAs lowered R5 to the floor. V5 stated the legs of the lift device are kept in the widened position while lifting resident off bed until resident is in wheelchair. V5 stated during this transfer, the legs on the lift device were in the narrowed position. On 3/25/2022 at 12:20pm, V6, CNA, stated V6 was assigned to provide care for R5 on 2/7/22. V6 stated R5 had to go to [CONDITION(S)], so V6 asked V5, CNA, to assit with getting R5 into wheelchair. V6 stated a mechanical lift device was used to transfer R5 from bed to chair. V6 stated the sling was placed under R5 and the straps connected to the lift device. V6 stated V6 was holding the wheelchair while V5, CNA, operated the lift device. V6 stated V5 pulled the lift device legs out from under the bed and was trying to position lift device between the wheels of wheelchair. V6 stated the device started tilting forward. V6 stated V5 tried to push device upright, but due to the weight of R5 and the weight of the device, V5 was unsuccessful. V6 stated V6 moved the wheelchair out of way and both CNAs lowered R5 to the floor. V6 stated when the legs of the lift device are pulled out from under bed, the legs are in the widened position. V6 stated you need to close the legs narrow when positioning it. V6 stated the device is more stable when the legs are widened. On 3/29/2022 at 7:55am, V12 (Restorative Aide) stated V12 is responsible for training staff on mechanical lift device protocols. V12 stated the legs of the mechanical lift device remain widened throughout the transfer of a resident from bed to chair or vice versa. V12 stated this ensures the lift device does not tip over; it keeps the device stable. V12 stated two staff are required for all transfers with a lift device. V12 stated one staff member operates the controls and steers the device while the other staff member should be standing next to the resident to guide the resident into the chair. V12 stated V5 and V6 were re-educated and competencied after this event.

Based on interviews and record reviews, the facility failed to ensure adequate supervision to prevent a fall out of bed for one resident (R1) out of 4 residents who required two person assistance with ADLs (activities of daily living) in a sample of 4. This failure resulted in R1 sustaining bruising to left side of face and a laceration to left eyebrow requiring sutures. Findings include: Review of R1's MDS (Minimum Data Set), dated 12/8/2021, notes R1 requires extensive assistance of two plus persons physical assistance with bed mobility. Review of R1's previous MDS assessments note R1 has required extensive assistance of two plus persons physical assistance with bed mobility since 4/15/2021. Review of R1's bed mobility documentation, dated 12/23/21-1/25/22, notes R1 requires extensive to total assistance with bed mobility. Review of R1's hospital record, dated 1/10/2022, notes R1 with laceration to left eyebrow requiring 6 sutures. R1 with bruising to left side of face. Review of R1's OT (Occupational Therapy) note, dated 1/12/2022, notes R1 is dependent on staff for bed mobility and transfers. R1 requires substantial/maximal assistance (upper body sponge bathing with maximum assistance, lower extremity sponge bathing with total dependence on staff). Range of motion to right and left arms is impaired. Right and left arm strength is impaired. Right and left hand grip strength are poor. On 1/21/2022 at 10:15am, R1 was observed lifting right arm off bed. R1 was able to lift right shoulder slightly off bed. R1 was observed lifting left arm slightly off bed. R1 is observed with a healed wound to left eyebrow and green/yellow discoloration to left side of face. On 1/25/2022 at 10:55am, V6, CNA (Certified Nurse Aide) was observed giving R1 a bed bath. R1 was observed holding the siderail with right hand when turned towards R1's left side. R1 was observed not to be able to hold self on to left side even while holding siderail. R1 does not have a siderail on the right side of bed to hold on to when turned on to right side. On 1/21/2022 at 10:15am, R1 stated about a week ago, V6, CNA, was giving R1 a bed bath. R1 stated V6 turned R1 on to R1's right side. R1 stated the mattress and R1 were wet, and R1 slid off bed, hitting head and sustaining a laceration to left eyebrow. R1 stated there is supposed to be two staff members to assist with R1's bath; V6 should not have done by self. R1 stated R1 is unable to assist with turning or maintain a side lying position on own. On 1/21/22 at 1:15pm, V4 (Director of Rehabilitation Therapy) stated R1 may be able to partially lift shoulder off bed to reach arm over body, but not able to turn self. V4 stated R1 has exhibited a progressive decline in functional ability over past year. V4 stated R1 is essentially immobile, requiring total assistance from staff for ADLs. On 1/25/2022 at 12:40pm, V2, Director of Nursing, DON stated R1 was not care planned for two person assist with bathing prior to fall out of bed on 1/10/22. V2 stated R1 required one staff to assist with bed mobility.

Based on observations, interviews, and record review, the facility failed to provide nursing assistance for feeding residents who are unable to carry out Activities of Daily Living (ADL) to prevent the residents from being hungry and help maintain good nutrition. This applies to 3 of 3 residents (R12, R62, R75) in a sample 25, reviewed for ADL care. As a result, R12, R62 and R75 expressed being hungry and seeking assistance from anyone to get food. Findindgs include: On 11/3/2021 from 12:10 PM to 2:44 PM, the surveyor made continuous observations of R12, R65, R75 during lunch hours, not receiving assistance with eating or feeding. 1. R12's lunch tray sitting on R12's bedside table away from R12. Surveyor observed resident continuously, and no staff members entered the room to assist with the meal. R12 stated, No one informed me my food was here. I am hungry can you feed me? On 11/3/2021 at 2:50 PM, V12 (Licensed Practical Nurse- LPN) stated, He (R12) should've been fed. I will feed him now. He should've been feed within 20 minutes after passing trays. On 11/3/2021 at 3:17 PM,during an interview with V2 (Director of Nursing-DON) V2 stated V19 (Certified Nursing Assistant, CNA) was busy feeding someone else. We usually pass out the tray to those who are self- feeders first and pass out the trays for those needing assistance last. Reasonable time would be less than one hour to feed the residents needing assistance with meals. R12 has left elbow/wrist/digits contractures. R12's care plan indicated supervision at mealtime required= 91-100% of the time. R12's speech therapy evaluation and plan of treatment documentation indicated on 10/28/2021 due to documented physical impairments and associated functional deficits .the patient is at risk for: aspiration, compromised general health and pneumonia. On 11/4/2021 at 2:27 PM, interview with V13 (Dietician) stated R12 has been on V13's list since July 2021 due to significant weight loss. V13 states it's possible that not eating in timely manner may affect R12's weight loss. On 11/4/2021 at 9:53 AM, V15 and V16 (Restorative Aides) weighed R12 on a mechanical lift; current weight at 141.5 pounds. R12 has lost 51 pounds since admission in 5/2021. 2. On 11/3/2021 at 1:45 PM, R62's lunch tray was placed next to the resident. R62 asked the surveyor, Are you here to help feed me? I am hungry and need help. R62's speech therapy's note on 10/27/2021 indicates diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient needs assistance feeding self? = yes. Supervision: how often does patient require supervision/assistance at mealtime d/t swallow safety? = 91-100% of the time. 3. On 11/3/2021 at 1:50 PM, R75 was laying on R75's side in bed, and the lunch tray was on dresser. R75 stated to the surveyor, I'm hungry honey, please feed me. You gonna feed me honey? R75's occupational therapy 10/28/2021 notes indicate eating dependent. Cognition moderately impaired. R75's Occupational therapy 10/29/2021 notes indicate R75's Current referra.l Patient referred to PT due to exacerbation of decrease in functional mobility, falls/fall risk, functional limitation with ambulation, increased need for assistance from others and increased physical exertion during daily living tasks .

Based on interview and record review, the facility failed to follow their Skin Management Policy, and failed to immediately assess and treat a new skin impairment for 1 of 3 residents (R2) reviewed for pressure ulcers in a total sample of 6. This failure resulted in R2 developing a pressure ulcer to the right ischium and buttock that was debrided and classified as a stage 4 ulcer. Findings Include: The face sheet documents R2 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician's Wound Assessment, dated 6/19/20, documents on admission, R2 was observed with a stage 3 pressure ulcer to the left buttocks and a deep tissue injury to the left heel. The Nurse's Notes, dated 5/3/21, documents during ADL care staff observed a pressure ulcer forming on the right gluteal fold that measured 2.5cm, and the wound nurse was notified. The Wound Assessment, dated 5/19/21, documents R2 was noted with new skin impairments, an unstageable wound to the right ischium and an unstageable wound to the right hip. The Treatment Administration Records for May documents treatments were initiated on 5/18/21. The Nurse's Notes, dated 6/8/21, documents R2's wounds to the right ischium and right hip were debrided by the Physician and were classified as stage 4 pressure ulcers after the procedure. The Nurse's Notes, dated 6/12/21, documents R2 was noted with body tremors and transfered to the hospital for evaluation. The Hospital Records, dated 6/12/21, documents R2 was admitted with altered mental status and increased shaking. R2 was noted with a stage 4 pressure ulcer to the right hip and the right buttocks. R2 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/29/21 at 2:00 PM, V12 (Wound Nurse) stated, Initially R2 was being seen for a [CONDITION(S)] tumor. The Nurse reported seeing an area to the right hip. I don't recall being told anything about the right ischium prior. I'm not sure of when I was notified but I saw the resident once I was informed of the skin breakdown to the hip and I did a body assessment and notified the Wound Doctor about the wounds. On 8/3/21 at 2:05 Pm, V11 (Wound Nurse) stated, When the staff identifies skin breakdown and inform us, a skin assessment is done no later than the next day. The Nurse that identified the area is responsible for notifying the family and calling the Doctor to get treatment orders until we come in and assess the resident. On 8/3/21 at 4:05 PM, V16 (Wound Nurse) stated, I noticed that R2 was developing a pressure ulcer in the area of the gluteal fold. I reported it to the regular staff. When you notice skin issues you are supposed to notify the wound care nurse and they take over from there. I told the wound care nurse and the resident was put on the list to be seen. I'm not sure of the name of the nurse that I spoke to or when the resident was seen. I did not notify the Doctor or the resident's family. I did not treat the area, I left it to the wound nurse. The Skin Management Policy documents the facility will ensure residents that are admitted to the facility are evaluated to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. The facility will properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures, and to provide appropriate treatment modalities for wounds according to industry standards of care. If a resident is admitted with or there is a new development of a pressure ulcer, staff will consult the Physician and resident representative and re-evaluate the resident's care plan and risk factors.

Based on interview and record review, the facility failed to ensure resident's safety by not maintaining a resident's bed in the lowest position. This failure resulted in R8 falling out of bed, sustaining a fractured right hip, and requiring surgical intervention. The facility also failed to ensure a resident was safe during personal care, which resulted in R9 falling out of bed, sustaining a laceration to the left side of her head requiring staples. This applies to 2 of 3 residents (R8, R9) reviewed for falls with injury in the sample of 14. The findings include: 1. R8's Fall Risk Assessment, dated 3/2020, shows R8 is high risk for falls. R8's fall risk assessment, dated 5/3/2020, shows, recent falls-Yes, Generalized Weakness-Yes, Confusion-Yes. R8 remains to be at high risk for falls. R8's Physician order [REDACTED]. R8's Minimum Data Set Assessment (MDS), dated [DATE], documents R8 is severely cognitively impaired. R8's MDS also documents that R8 has no behaviors. R8's Care Plan, initiated on 3/28/2020, shows R8 is at risk for falls due to history of repeated falls with interventions that include, bed in the lowest position. The same care plan shows on 5/3/2020, (R8) fell and was sent to the emergency room . On 5/9/2020, R8 was readmitted to the facility with [DIAGNOSES REDACTED]. R8's care plan intervention include, initiate low bed and floor mats around bed upon readmission. The facility Final Report regarding R8, dated 5/8/2020, sent to the State Agency documents, (R8) is an [AGE] year old female. (R8's) admitting [DIAGNOSES REDACTED]. The facility has performed a full investigation. (R8) was observed lying on the floor in her room during the night The resident attempted to get out of bed and fallen during this time sustaining the fracture to the affected site The x ray had revealed a superolateral displacement of the (right) distal femur and she is currently in the hospital for treatment. Type of Injury-Fracture R8's progress notes written by V9, dated 5/3/2020, shows, (R8) yelling aloud from room. Noted (R8) lying on the floor, on left side of the bed lying on her right side. (R8) had bed elevated from the floor to the highest it will rise. Shade in the window was noted torn down next to (R8). All sheets and pillows were taken from bed, lying on the floor with (R8). When questioned, R8 said she had to get up there are snakes all over Reoriented back to reality but seemed unable to understand. Assisted back to bed. Complaining and guarded lower extremities. Paged out to on call (MD). X ray order received. (This progress notes did not document of R8 messing with her bed controls.) R8's radiology report, dated 5/3/2020, shows R8 had fracture of right femur. R8's Local Hospital Records entitled Summary of Episode, dated 5/4/2020, documents, [AGE] year old black female, fell and was found to have a [MEDICAL CONDITION] admitted to the hospital. Extremities, right leg is shorter compared to the left and externally rotated. The same hospital record also shows R8 has [MEDICAL CONDITION] humerus (left upper arm) A surgical report, dated 5/4/2020, shows R8 underwent right [MEDICAL CONDITION] repair (hip pinning). R8 was discharged back to the facility on [DATE]. On 11/10/2020 at 6:30 AM, V9 (Registered Nurse), said on 5/3/2020 she was the nurse when R8 fell and sustained a [MEDICAL CONDITION]. V9 said she cannot remember what happened. V9 said whatever she documented was what had happened. At 3:48 PM, V9 said when R8 fell out of bed, she saw R8 on the floor with her sheets and pillows and R8's shades in her windows was also torn. V9 said R8's bed was noted to be in the highest position, as high as it can go. V9 said R8 was more confused, and she might have adjusted her bed. V9 said R8 needed more frequent monitoring that time due to her increased confusion. V9 said R8 is high risk for falls due to increased confusion and previous repeated falls. V9 said R8's bed should be in the lowest position to prevent R8 from falling out of bed. V9 said she heard R8 was sent to the hospital and had surgery to repair the [MEDICAL CONDITION]. A progress note, dated 5/9/2020, shows R8 was readmitted to the facility with right hip surgical incision site with staples intact. On 11/9/ 2020 at 10:00 AM, R8 was awake, calm and quiet lying in a low bed. R8's bed had floor mats around her bed. R8 said she cannot remember regarding her fall months ago. On 11/9/2020 at 10:15 AM, V5 (License Practical Nurse) said R8 is confused and loves to stay in bed facing the window. V5 said R8 has no behaviors and does not mind being in her bed. V5 said R8 is high risk for falls and R8 needs frequent checks and frequent monitoring. On 11/9/2020 at 10:25 AM, V13 (Certified Nursing Assistant-CNA) said R8 is calm when in bed. V13 said she checks on R8 frequently. V13 said R8 had just had a fall lately. On 11/10/2020 at 12:10 PM, V22 (Nurse Practitioner-NP) said fall risk residents should be monitored closely. When these residents have increased confusion they should be checked more frequently. On 11/11/2020 at 11:30 AM, V2 (Director of Nursing) said resident's bed need to be maintained in the lowest position for safety. If a resident has a tendency to handle the bed controls, staff should ensure the bed was locked in the lowest position and controls were away from the resident. 2. R9's POS, dated 11/2020, shows R9 has [DIAGNOSES REDACTED]. R9's fall risk assessment, dated 1/31/2020 (admission), shows R9 is high risk for falls due to previous falls, generalized weakness and confusion. R9's MDS, dated [DATE], shows R9 is severely cognitively impaired. The same MDS shows R9 needs extensive assist of 2 or more staff for bed mobility, turning and repositioning in bed. R9's careplan, initiated on 2/29/2020, shows, (R9) Requires extensive assist with all ADL's. With intervention to include bed mobility Max assist with bed mobility. 4/30/2020, (R9) is high risk for falls due to decreased mobility, balance and endurance. Repeated falls 9/11/19, 2/24/20. On 4/23/2020 (R9) sent to ER with 10 staples to the left side of head. On 11/ 9/2020 at 11:15 AM, V18 (R9's family) stated, the facility caused (R9) my mother's fall with injury. The facility knew my mother (R9) was severely contracted on both arms and legs and cannot hold unto anything, she was immobile and totally dependent for all her care. Two or more staff was needed to provide care to (R9). The CNA was providing personal care by herself without any other staff in the room to ensure my mother (R9) was safe. When the CNA turned my mother (R9) to her side, (R9) slipped out of bed and fell on the floor. (R9) hit her head and needed to be sent to a local hospital. My mother (R9) received 10 staples for her [MEDICAL CONDITION]. The facility Final Report regarding R9, dated 4/29/2020, shows, (R9) is [AGE] year old with admitting [DIAGNOSES REDACTED]. Facility has performed a full investigation of R9's fall. The resident was unable to provide information on this event due to her cognition. (R9) was receiving ADL care at the time of the incident. The CNA turned her to her side and the resident began to slide and slid from the air mattress onto the floor. She was unable to prevent the injury. (R9) sustained a laceration to the left side of her head from the fall (R8) was sent to the ER for evaluation and treatment per MD's orders. Family was made aware. (R9) received ten staples to the affected site at the ER and returned to the facility. R9's progress note, dated 4/23/2020 by V8 (License Prctical Nurse-LPN), shows, R9 was on the floor during care while being changed by a CNA. CNA told writer that she slide out of bed while changing her. (R9) has hematoma and abrasion to her left side of head. NP was paged and was sent to the local hospital. R9's local hospital record, dated 4/23/2020, documents, Chief Complaint-Injury from fall. Diagnosis-[MEDICATION NAME] head injury, scalp laceration. Laceration care- staples. R9's progress notes dated 4/23/2020 shows R9 came back to the facility with 10 staples on the left side of head. On 11/9/2020 at 12:16 PM, V7 (Certified Nursing Assistant, CNA) said she was R9's CNA on 4/23/2020. V7 said she was providing morning care to R9. V7 said when she turned R9 to her side, R9 rolled out of bed and ended on the floor. V7 said R9 was lying on the floor bleeding. V7 said she quickly asked for help. V7 said R9 probably hit her head in the cabinet by R9's bed. V7 said she knew she needed help when taking care of R9 but no staff was available. V7 said R9 was contracted both with her arms and legs. V7 said she should have waited for staff to help her. On 11/9/2020 at 12:00 PM, V8 (LPN) said she was the nurse when R9 fell out of bed on 4/23/2020. V8 said when she entered the room, R9 was on the floor. V8 said V7 informed her that she was giving personal care to R9 when R9 slipped out of bed. V8 said R9 had [MEDICAL CONDITION] and was sent out to the hospital. R9 received 10 staples. V8 said R9 wiggles and squirms in bed. R9 had contractures both upper and lower extremities. V8 said it was safer to have 2 staff to take care of R9 for personal care. On 11/10/2020 at 12:20 PM, V22 (Nurse Practitioner, NP) said staff should follow the required number of staff when taking care of residents to prevent falls and injuries. The facility policy on Fall, with a revised date of 11/17, documents intervention to consistently identify and evaluate a residents at risk for falls and those who have fallen to treat or refer treatments appropriately and develop an organization-wide ownership for fall.

Based on interview and record review, the facility failed to have interventions in place for a resident with known [MEDICAL CONDITION] episodes, and failed to keep the high fall risk resident in a highly visualized area during awake hours for one (R8) of four residents reviewed for resident injury in regards to falls in a total sample of eight residents. This failure resulted in R8 receiving a total or 11 sutures to lacerations sustained to the forehead and lower lip, and broken dentures. Findings Include: R8 is an [AGE] year old with the following Diagnosis: [REDACTED]. R8 admitted to the facility on [DATE]. An Admission note on 9/26/19 documents R8 admitted for fall from home and requires assistance with transfers and care. A Nurse Practitioner note, dated 10/10/19, documents R8 examined and occasionally reports some dizziness, but there has been an improvement. A Daily Skilled note, dated 10/14/19, documents R8 requires supervision for safety. A Physician Note, dated 10/14/19, documents R8 denied dizziness, but reported lightheadedness with position changes, especially going form sit to stand. A Nurse Practitioner note, dated 10/23/19, documents R8 still needs supervision and a wheelchair for safe mobility. R8 is not a candidate to discharge without 24/7 supervision due to cognitive and functional issues. A Nursing note, dated 10/26/19 at 6:10AM, documents R8 noted sitting on the side of the bed and just finished using urinal. A Nursing note on 10/26/19 at 7:35AM documents the nurse was called to R8 ' s room by the CNA at 6:50AM. R8 noted lying face down with blood on the floor. On assessment, a laceration to the forehead and a cut to the lower lip was noted. Per the CNA, R8 observed standing by the side of the bed and said, I feel dizzy, and then slumped over and fell . 911 called, and R8 taken to the hospital for an evaluation. The Fall Risk Evaluation dated, 9/26/19, documents R8 with a score of 9, and on 10/26/19, documents R8 with a score of 15 (a score of 5 or higher is considered a high fall risk). The Incident Report, dated 10/31/19, documents R8 attempted to stand up unassisted and lost balance and fell to the floor. The Care Plan, dated 9/27/19, documents R8 is a risk for falls with interventions focusing on proper footwear and anticipating/meeting resident's needs. The Care Plan does not address resident's [MEDICAL CONDITION], lack of safety awareness, impulsivity, or need for increased supervision. The Hospital Records, dated 10/26/19, document R8 reported falling while trying to get out of the wheelchair after feeling dizzy. Per the ambulance, R8 did lose consciousness at the time of the fall. R8 noted with [MEDICAL CONDITION] and lower lip laceration, with broken teeth to dentures. Nine sutures were needed for the [MEDICAL CONDITION], and two sutures were needed for the lower lip laceration. R8 admitted to the hospital for observation due to being unable to recognize family members, which is not R8 ' s baseline. On 11/12/19 at 2:49PM, V8 (CNA) stated, I was in the isolation room across the hall finishing up care with that resident for the morning. I was taking off my isolation gear when I saw R8 stand up in R8's room. I tried to ask R8 hey what are you doing and sit back down. R8 said I feel dizzy and then R8 fell . I ran and told the nurse and when we came in he was bleeding on his forehead and mouth. R8 said R8 didn't remember what happened. R8 just fell when R8 was standing there. I never saw R8 take any steps. I don't know if he passed out. He just fell . No, he never said what he was trying to do. R8 did try to get up alone often so we would make sure we would check on R8 when we did our rounds. Yes, R8 was a high fall risk. R8 needed assistance with almost everything. I don't remember what interventions R8 had in place for falls. On 11/13/19 at 11:41AM, V9 (Nurse Practitioner) stated, R8 was admitted for a debilitating fall from a syncopable episode and spending hours on the floor. I know R8 was on the second floor and that is where residents that need to be watched more closely for falls are placed at that facility. I know R8 was a high fall risk based on R8's confusion and ataxia, and R8 wasn't progressing that much in therapy. If you look at one of my last notes on R8 speaking on discharge I wrote that R8 will require 24 hour supervision at home because of R8's falls and because of R8's cognition. Yes, R8 did have a history of syncopable episodes but I can't what the facility should have done more to keep R8 safer. That is a decision that is up to them. All I can say was that R8 was on the second floor, and R8 shouldn't having been getting out of bed without assistance. On 11/13/19 at 11:53AM, V10 (Nurse Consultant) stated, R8 was getting physical and occupational therapy for having a fall at home and being on the floor for a prolonged period of time. R8 lived alone before R8 got here and that was R8's goal to go back home. R8 was extensive assistance just moving side to side in the bed. Even walking with the staff wasn't done, being it was deemed as not being safe. R8 was only allowed to do walking with therapy. R8 did want to exert independence and when R8 got here R8 probably didn't want to lose that. The interventions are individualized and generally if they have a history of falls we put that in the care plan right away. It is always individualized for that specific person's needs. We have a general fall form and it starts at admission with the assessment for falls. R8 scored a 9 and a 5 is considered a high risk so R8 was off the charts. R8 was always escorted to the restroom and are always in high visual areas during awake hours. R8 was also in a restorative program to promote independence. The fall care plan focused on his shoes and brakes being locked on the bed and wheelchair. The appropriate shoe wear was focused on because he was in the walking program both PT and restorative. We didn't put anything in R8's care plan about the [MEDICAL CONDITION] because that is not something you can care plan. R8's BIMS score was a 14 so R8 was way cognitively intact. I think this fall was just a moment of impulsivity. Based on the documentation, he had decreased safety awareness. We had several meetings with the family and they continued to say they wanted to go home alone but it was decided he couldn't do that. The only thing that we could have done is do rounds on R8 to keep R8 safe. In R8's note it, says that R8 requires supervision for safety. We round on residents like this every hour. The nurse does one hour and the CNA does the next hour. On 11/13/19 at 12:44PM, V11 (RN) stated, I remember I was in R8's room that morning at around 6 to do his vital signs, and R8 was fine. R8 used the urinal and was sitting on R8's bed. I went back to the nurse's station to finish up and chat with the other nurses coming on for the day when the CNA yelled for me down the hall. I came down to R8's room and saw R8 lying on the floor face down, and R8 was bleeding. When I asked R8 what R8 was doing R8 told me R8 doesn't remember what happened. Yes, he was a high fall risk. We try to consider all residents high fall risks to keep them safe. No, R8 shouldn't be allowed to get up alone because R8 needs help getting up. R8 wasn't a high priority resident to get up out of bed when I saw R8 the first time so I left R8 there. Thinking back now, I should have laid R8 back down in the bed until R8 was going to get up on the day shift.

Based on interviews and record reviews the facility failed to develop an individualized fall care plan for a cognitively impaired resident who was a high fall risk for falls for 1 (R1) out of 7 residents reviewed for falls. This failure resulted in the resident falling and sustaining a fracture in the right hip. Findings include: Record review of R1's admission record reads R1's [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated 05/04/17 reads R1 required extensive assistance with bed mobility, transfer, locomotion on and off the unit, dressing, eating, and toilet use. Record review of R1's fall evaluation scores read R1 was a High Risk of Fall. R1's 05/04/17 MDS also reads R1 had severe cognitive impairment. Progress note dated 05/04/17 at 07:48 AM written by V4, Social Services Director, reads Patient is very inconsistent, physically (R1) is able to do a lot but cannot follow commands. Safety insight is very poor. Conversations are non-sensical (sic). Reviewed R1's Physical Therapy and Plan of Treatment note dated 4/21/17 which reads R1 was at risk for falls and increased dependency upon care givers. Fall predictors included R1's reduced insight for unsafe situations and reduced recognition of unsafe situation. R1's care plan reviewed. Interventions initiated upon admission included: Ensure that the resident is wearing appropriate footwear Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Follow facility fall protocol. PT (Physical Therapy) to evaluate and treat as ordered or PRN (as needed). On 01/16/19 at 12:36 PM, V9, Consultant, stated R1 was a risk for falls. V9 stated R1 had multiple falls with the most recent one at the facility being 05/11/17. Record review of progress notes read that R1 had a fall on 04/28/17, 05/04/17, and 05/11/17. Record review of R1's 'Braden/Fall/Wander/Neuro/Hydration/Transfer' reports and care plan read that after the 4/28/17 fall, a chair alarm was added for fall interventions. Records also read that after the 05/04/17 fall, a bed alarm was added for fall interventions. However, on 01/17/19 at 1:43 PM, V23, Fall Coordinator, stated cognitively impaired residents will not know what the bed or chair alarm pertains to. V23 stated the alarms can scare the resident and increase their risk for fall. V23 stated cognitively impaired residents should be care planned for frequent monitoring, frequent toileting, and frequent rounding to check to see if their needs are met. On 01/18/19 at 09:55 AM, survey team reviewed R1's care plan with V2, Director of Nursing. Surveyor asked V2 to elaborate on the intervention Follow facility fall protocol. V2 stated facility's Fall Protocol is within the facility's Fall Evaluation Safety Guidelines. At 10:16 AM, V2 stated after the initial fall assessment there should be listed interventions underneath the section Follow facility fall protocol. Listed intervention reads, PT to evaluate and treat as ordered or PRN. On 01/18/19 at 10:30 AM, V24, Therapy Manager, stated for an individual like R1, therapy would recommend constant supervision. V24 stated R1 should not be left alone unsupervised for long periods of time. V24 stated R1 needed to be placed where he can be supervised at all time because R1 needed constant supervision with 1-2 assist with transfer. V24 stated this was discussed during the daily morning meetings. On 01/18/19 at 11:38 AM, V2 stated nurses should initiate frequent rounding and monitoring for cognitively impaired residents. On 01/18/19 at 1:26 PM, V26, MDS and Care Plan Coordinator, stated each resident gets a fall risk care plan upon admission. V26 stated basic care plan will include making sure appropriate foot wear is on, call light in reach, and PT to evaluate. V26 stated additional interventions can be added as needed. On 01/23/19 at 11:50 AM, V26 stated falls are discussed during morning meetings with IDT (Interdisciplinary team). V26 stated the facility will discuss possible interventions to prevent falls and update the resident's care plan as needed. V26 and V32, MDS and Care Plan Coordinator, stated both can update the care plans including the nurses, managers, and V2. Fall incident report and investigations for R1's fall on 5/11/17 reads R1 was observed on the floor in the dining room a few inches from the wheelchair. R1 attempted to walk resulting in fall. Report reads V13, assigned nurse, was passing medications and V12, assigned CNA (Certified Nursing Assistant), was in another resident's room. Progress note dated 05/12/17 at 11:06 AM reads R1 was having signs and symptoms of right leg pain. Order was given to send R1 to the emergency room for further evaluation. X-ray of the bilateral hip and pelvis transcribed on 05/12/17 at 02:07 PM, reads Acute intratrochanteric [MEDICAL CONDITION] hip. Reviewed facility's 'Careplan Standard Guideline' which reads Interventions should be specific to reflect the specific goal. The intervention should be individualized to the resident. Reviewed facility's 'Fall Evaluation Safety Guideline' which reads Residents who are evaluated as being at risk for falls will be identified and individualized fall precautions will be developed for each resident. Preventative measures shall be taken to decrease the number of falls whenever possible. Guidelines include multiple recommendations for strategies on managing falls in relation to confusion, weakness/unsteady gait, and multiple falls. However, when compared to R1's care plan, interventions only included chair/bed alarms, wearing appropriate footwear, call light within reach, follow facility fall protocol, and physical therapy to evaluate and treat as ordered and needed. Listed interventions also did not include frequent monitoring or rounding on R1 as staff stated was needed for cognitively impaired residents.

Based on observation, interview and record review the facility failed to immediately start chest compression on an unresponsive resident; failed to place a low air loss mattress in the proper setting for cardiopulmonary resuscitation (CPR), failed to have needed supplies in the emergency cart for suctioning and failed to deliver oxygen at level that is most beneficial to a resident during cardiopulmonary resuscitation. These failures apply to one of three residents (R5) reviewed for emergency care service in a sample of three. After emergency services were provided by paramedics, R5 was pronounced dead at the hospital. These failures also have the potential to affect 83 of 117 residents with a full code status including 13 residents on low air loss mattresses. Immediate jeopardy was identified on [DATE] when staff members (E2, E7, E8) failed to initiate CPR immediately per the American Heart Association Guidelines as indicated per facility's policy and have equipment available for use during emergency procedures. E1 (Administrator) was informed of the immediate jeopardy on [DATE] at 12:36pm. The immediate jeopardy was removed on [DATE] at 3:38pm. On [DATE] at 3:38 pm, while it was determined that the immediacy was removed, the facility remains out of compliance at a severity level 2. The facility needs to monitor and evaluate the effectiveness of the facility's staff education and revised policies and procedures. Findings include: On [DATE], the following events were timed and documented by this surveyor as they occurred during R5's emergency code. The timed events show a delay of five minutes (12:55pm - 1:00pm) to start chest compressions and four minutes (1:00pm - 1:04pm) of providing chest compressions with questionable effectiveness due to lack of cardiac board and special mattress which was not in CPR mode, and failing to maintain a clear and patent airway (during CPR) due to malfunctioning suction machine and providing inadequate oxygen via resuscitator bag, in the process. On [DATE] at 12:55pm, E2 DON (Director of Nursing) and this surveyor were doing observations and rounds when this surveyor noticed that R5 did not appear to be breathing. This surveyor asked E2 to assess R5 and it was discovered that R5 was not breathing and had no pulse. E2 stepped outside of R5's room and called out for help. Afterward, E2 returned back into R5's room but did not provide R5 with any chest compressions or rescue breaths. It was 5 minutes before CPR was initiated, when E7 Licensed Practical Nurse (LPN) arrived at R5's bedside, although E2 DON remained in R5's room after the initial assessment. The back board was not placed underneath R5 and R5's low air loss mattress was not placed in CPR mode (mattress deflation) until after CPR was initiated. The head of the bed was not lowered until after CPR was initiated. On [DATE], at 1:00pm, E7, Licensed Practical Nurse (LPN) entered R5's room and began chest compressions on R5 while the head of the bed remained in the upward position. E7 did not use a backboard or place R5's low air loss mattress on CPR mode (mattress deflation). On [DATE], at 1:02pm, E8 (LPN) took over R5's chest compression while E7 (LPN) connected the oxygen delivery bag to an oxygen tank at two (2) liters of oxygen and applied the Automated Electronic Defibrillator to R5. At this same time, E11 (Central Supply Clerk) was observed lowering the head of the bed. Immediately following E12, Licensed Practical Nurse (LPN) was observed placing the back board underneath R5. E12's LPN written interview/statement dated [DATE] indicates that E12 saw R5 receiving CPR; found R5's bed without a back board, retrieved the back board and placed it underneath R5. On [DATE], at 1:04 pm, E9 (LPN) entered R5's room and placed R5's low air loss mattress in CPR mode (deflated the mattress) and turned the oxygen tank that was connected to the manual oxygen delivery bag up to 15 liters. R5's low air loss mattress was immediately re-inflated by E11 (Central Supply Clerk), despite E9 LPN announcing that the deflation of the mattress was the CPR mode. On [DATE], at 1:08 pm, the paramedics arrived to R5's room. The paramedics run sheet dated [DATE] indicates R5 did not have respirations, heart rate or blood pressure. The paramedics, while placing a breathing tube into R5 requested suction equipment from staff present in the room. The paramedics requested suction and the facility's code cart was not stocked with suction supplies. E11, Central Supply Clerk was observed running down the hall to retrieve suction supplies, although the emergency cart was at the door of R5's room. On [DATE], at 1:10 pm, E7, LPN brought the suction machine into R5's room. The suction machine turned on but did not suction properly. On [DATE], at 1:22 pm E2, DON requested this surveyor's timeline stating she needed documentation of R5's code. The facility has not been able to provide a checked and signed code cart supply list as evidence that the emergency cart was being checked and restocked routinely as indicated in the facility's Crash Cart policy (dated ,[DATE]). According to R5's Physician order [REDACTED].>On [DATE], at 1:35 pm E8 (LPN) stated R5 was a full code. When asked what procedure should be followed when a resident is found unresponsive, E8 stated that you should call for help and immediately start CPR. On [DATE], at 1:45pm when asked how the emergency carts are checked, E4 (LPN) stated that the emergency carts should be checked nightly. On [DATE], at 3:00 pm when asked when the emergency carts are checked E2, DON stated that the emergency carts should be checked at night by the night supervisor and an e-mail is sent to the supply clerk for replacement supplies needed. On [DATE], at 2:54 pm when asked what procedure is followed when a resident is found unresponsive, E9 (LPN) stated when a resident is found unresponsive you assess the resident, call for help and start one person CPR. E9 stated that you do not wait for a second person to start CPR. E9 stated she placed R5's bed in CPR mode for more effective chest compressions and increased R5's oxygen from 2 liters/minute to 15 liters/minute to provide more effective oxygen delivery. When asked how the emergency carts are checked, E9 stated that emergency cart should be checked nightly. On [DATE] at 5:29 pm during the daily status meeting, E1 Administrator stated that the emergency cart was locked when she brought it to R5's room during the code. On [DATE] at 9:30am E1 Administrator stated that R5's bed was mistakenly re-inflated during CPR by the central supply clerk who was at the foot of the bed during R5's code. On [DATE], at 10:54 am E2 (DON) stated she did not initiate CPR on R5 because R5's bed was not flat and she was trying to keep R5's airway open. When asked if R5 had a pulse or respirations upon initial assessment, E2 stated that R5 was not breathing and had no heart rate upon initial assessment. When asked what should have been done for R5 after calling for help, E2 stated that chest compressions should have been initiated on R5 right away. On [DATE], at 11:42 am Z2 (R5's Physician) stated compressions should be started right away when a resident is found unresponsive and are more effective with a hard surface to provide more resistance. On [DATE], at 2:35pm E14, LPN was asked what procedure is followed when a resident is found unresponsive, E14 stated that when a resident is found unresponsive with no pulse or respirations CPR is initiated immediately after calling for help. On [DATE], at 2:40 pm E15, LPN was asked what procedure is followed when a resident is found unresponsive, E15 stated that CPR is initiated immediately after an assessment and a call for help is done when a resident is found unresponsive with no pulse or respirations On [DATE], at 8:37 am E11, Central Supply Clerk stated that she lowered R5's head of the bed during Cardiopulmonary Resuscitation (CPR). E11 stated that she noticed that the bed was going flat and thought someone accidentally hit the wrong button so she (E11) re-inflated R5's bed. When asked what her role was during the code, E11 stated that she was present during R5's code to provide additional assistance to the staff. According to the low air loss manufacturer's guidelines (undated) the CPR function deflates the whole mattress within seconds after a simple touch on the button in case of emergency. According to the facility's emergency checklist the emergency cart should contain suction catheter kit, suction extension tubing and suction tip. On [DATE], at 8:27 am E7, LPN stated that he brought the suction machine into R5's room after receiving the suction supplies that were missing from the emergency cart from E11. E7, LPN stated that the suction machine was not extracting secretions. E7, LPN stated the suction supplies should be inside of the emergency cart. On [DATE], at 8:37 am E11, Central Supply Clerk stated that the suction supplies should be in the emergency cart. When asked if the suction supplies were on the emergency cart, E11 stated that the suction supplies were not on the emergency cart during R5's code. When asked how she (E11) knows the listed supplies are in the emergency cart, E11 stated that when the emergency cart is locked the list of supplies should be on the cart. On [DATE], at 12:45 pm E11, Central Supply Clerk stated that she has been the Central Supply Clerk for two (2) years. When asked if she has had CPR certification in the last two (2) years since becoming the Central Supply Clerk, E11 stated that she has not had CPR re-certification since becoming the Central Supply Clerk. The facility could not provide a CPR card for E11. On [DATE], at 1:33pm E12, LPN stated that she entered R5's room on [DATE] during a code blue and noticed that R5 was receiving chest compressions without a back board underneath her. E12 stated that she went to the crash cart that was located outside of R5's room, removed the back board from the back of the crash cart and place the back board underneath R5. When asked why the back board was placed underneath R5, E12 stated that the back board makes the chest compression more thorough. On [DATE], at 2:40 pm Z3 (Medical Director) stated that if the code status of a resident is unknown then Cardiopulmonary Resuscitation (CPR) should be initiated until the code status is established. When asked if the facility follows the American Heart Association (AHA) guidelines for oxygen delivery during a code, Z3 stated that the facility's policy has been revised to deliver 15 liters/minute of oxygen to meet the AHA guidelines. According to the facility policy entitled code blue/medical emergency protocol (undated), if a resident is unresponsive; initiate CPR following the American Heart Association guidelines per resident ' s code status if patient is not Do Not Resuscitate. The American Heart Association guidelines indicates under bag-mask ventilation that the healthcare provider should use supplementary oxygen (O2 concentration >40%, at a minimum flow rate of 10 to 12 L/min) when available. On [DATE] during R5's emergency code supplemental oxygen was available but was titrated to deliver 2 liters/minute of oxygen. The facility's emergency procedure - Cardiopulmonary Resuscitation Policy dated [DATE], indicates that if an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: DNR (Do Not Resuscitate) order prohibits CPR or obvious signs of irreversible death. On [DATE] at 1:00pm during the initial assessment E2 DON was observed touching R5's chest and stated that R5 was still warm. The facility Crash Cart Guideline, dated [DATE] indicates in part that facility staff should: assess daily for secured lock/seal; have consistent shift for checking; replace all supplies. The facility submitted the following actions as part of their removal plan and was accepted on [DATE] at 3:38 pm. 1.) The affected resident is no longer at the facility; therefore specific corrective action cannot be taken for her. 2.) The facility has identified all residents who are a full code as having the potential to be affected by this alleged deficient practice. 3.) The facility immediately implemented the following measures and systems post incident. These measures and systems will assure that this alleged deficiency does not recur: a. The DON received 1x1 training by CPR Instructor from the Ambulance service regarding the steps of CPR with specific discussion on the importance of initiating compressions timely b. Nursing staff was re- in serviced regarding code blue policy beginning on [DATE] through [DATE] 4.) Nursing staff has been in-serviced regarding all aspects of emergency procedures. Specifically discussed: · Code Blue Policy - [DATE] to [DATE] · Crash Cart Supply Check-list - [DATE] to [DATE] · Policy for Restocking Crash Carts after Code Blue - [DATE] to [DATE] · Proper deflation of APM and Low Air Loss Mattresses in a Code Blue - CPR Mode - [DATE] · Assembling Suction Machine Properly and Use - [DATE] · In-servicing of Nursing Staff as to where to identify Code Status - [DATE] · [DATE] the Medical Director approved the additions to the Code Blue/Medical Emergency Protocol that addressed the items discussed during in-services, that included O2 at 15 liters, ensure resident is on hard surface, code status is verified in chart, set up suction machine as needed. · On [DATE], an addition to the emergency crash cart monitor form has to include detail on what to check for regarding the suction machine and the oxygen tank 5.) The Administrator, Regional Nurse Consultant, DON and/or their designees will conduct audits daily for 3 days then weekly for 4 weeks by conducting random · Mock code blue drills · Crash cart audits to ensure the sign out sheet is completed and visible items are present. · CPR instructor from the ambulance company conducted Mock Code Blue Drills and competencies - [DATE] and ongoing. Noted issues will be addressed immediately and will be brought to the QA for further action. Completion Date: [DATE]

Based on observation, interview and record review the facility failed to use safe and proper technique for resident transfer and wheelchair transport, to keep beds in the lowest position, to provide and ensure placement of fall mats and to provide and ensure proper operation of bed alarms for three (R1, R2 and R3) residents out of three in the sample of three. This failure resulted in R1 falling from a wheelchair during transport causing an open laceration to the right side of the head requiring nine staples. Findings Include: 1. R1's face sheet [DIAGNOSES REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] indicates R1 is totally dependent requiring two or more person assistance for bed mobility, and transfers. R1's MDS indicates R1 has impairment to bilateral upper and lower extremities and is severely cognitively impaired. On 3/16/15 at 12:40 pm R1 was observed resting in bed. E5 (Unit Manager) stated R1 is non-verbal and cannot move herself. R1 did not respond to this surveyor verbally. R1's incident report dated 3/15/15 indicates R1 was observed by Certified Nursing Assistant sliding from the wheelchair and bumping her head on the floor. R1's fall risk observation dated 3/15/15 indicates R1 is at high risk for falls. R1's fall care plan initiated 6/10/14 includes an intervention for low bed. R1's Minimum Data Set ((MDS) dated [DATE] indicates R1 is totally dependent with two or more person assistance for bed mobility and transfers. R1's MDS indicates that R1 has mobility impairment on bilateral upper and lower extremities. R1's activities of daily living functional /restorative record dated 2/4/15 indicates R1 is to be transferred using a mechanical lift up in a specialized wheelchair. R1's hospital physician notes dated 3/14/15 indicate R1 was treated in the local emergency room for a laceration to the right occipital area and required 9 staples. R1's computed tomography of the head dated 3/15/15 indicates R1 had a right scalp hematoma and no intracranial hemorrhage was identified. On 3/16/15 at 2:40 pm R1 was observed resting in bed which was noted in a high position. E6 (RN/ Registered Nurse) who was present at the time stated, R1's bed was not in the lowest position and proceeded to lower R1's bed. E6 stated R1 had just been repositioned and the bed was left in the high position. R1 was observed with staples to the right side of her scalp. On 3/16/15 at 3:00 pm Z1 (Family) stated the facility informed her that R1 suffered a fall from the wheelchair while being transported to her room. Z1 stated the facility informed her that R1 fell on her face when the blanket became entangled in the wheels of the wheelchair pulling R1 to the floor. On 3/18/15 at 10:15 am E4 (certified nurse aide/ CNA) stated R1 was transferred from the bed to the wheelchair with E3 to transport R1 to a different room. E4 stated E3 rolled the wheelchair backwards while E4 held R1's legs up. E4 stated she accidentally stepped on R1's blankets and R1 fell out of the wheelchair bumping her head, causing bleeding. E4 stated R1 was lifted off the floor by E3 (RN) and E4 and carried to the bed and 911 was called. On 3/18/15 at 2:42 pm E3 stated R1 was transferred from the bed to the wheelchair using two person assistance without the mechanical lift. E3 stated R1 was placed in a standard wheelchair with a blanket covering the wheelchair to transport R1 to a different room. E3 stated during the transport of R1 she rolled the wheelchair while E4 held R1's legs up. E3 stated R1 did not bump her head on the floor but was lowered to the floor. E3 stated R1 was noted to have bleeding from her head and was lifted by E3 and E4 and carried to the bed. On 3/18/15 at 3:00 pm E2 (Director of Nurses/ DON) stated it is not acceptable to move a resident once bleeding is noted from the head. E2 stated R1 should not have been transferred without the use of a mechanical lift and a specialized wheelchair. 2. R2's face sheet [DIAGNOSES REDACTED]. R2's progress note dated 2/10/15 indicates R2 was observed on the floor close to her bed. R2's progress note indicates R2 did not suffer any injury. R2's incident report dated 2/10/15 indicates R2 was reaching for the call light and slid onto the floor from the bed. R2's incident report indicates R2 was placed back in bed by family who failed to put R2's call light within her reach. R2's fall care plan dated 11/04/2014 includes interventions for a bed alarm, mattress on side of bed (fall mat) and an anti-slide pad in the wheelchair. On 3/16/15 at 2:30 pm R2 was observed resting in bed without a fall mat or bed alarm in place. On 3/16/15 at 4:00 pm with E1 (Administrator) and E2 (Director of Nursing) R2 was observed in her room in the wheelchair. R2 was observed with a specialized cushion but no anti-slide pad in place in the wheelchair. R2's room was searched by E1 and E2 with no fall mats located and no bed alarm was observed attached to R2's bed. On 3/16/15 at 4:10 pm E7 Certified Nursing Assistant (CNA) stated R2 does not have a fall mat. 3. R3's face sheet [DIAGNOSES REDACTED]. R3's incident report dated 3/5/15 indicates R3 was observed on the floor in his room. R3's report indicates R3's roommate observed R3 bending over to retrieve his newspaper and fell from his wheelchair. R3's incident report indicates no injury was observed. R3's incident report under immediate action taken includes application of personal safety alarm. R3's incident report dated 3/8/15 indicates rolled out of bed. R3's report does not indicate whether R3 was found on the floor or if he was receiving care when fall occurred. On 3/16/15 at 2:50 pm with E8 Licensed Practical Nurse (LPN) R3 was observed resting in bed with no fall mat in place and a bed alarm in place but was not powered on. E9 CNA stated R3's family had just left and did not put the fall mat in place. E9 stated R3 has the bed alarm because family requested it. On 3/18/15 at 1:00 pm E10 Unit Manager stated if the bed alarm is in place it must be turned on. E10 stated R3 has the bed alarm at the family request. E10 stated R3 was observed with his legs hanging out of the bed on 3/8/15 and did not fall on the floor. E10 stated R3's 3/8/15 incident was classified as a change of plane. The facility's Assessing Falls and Their Cause policy revised October 2010 indicates once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position and then document relevant details. The facility's Room to Room Transfer policy indicates staff should follow safety precautions while transporting the residents. On 3/18/15 at 3:45 pm E1 and E2 stated standard safety precautions include environment free from clutter. The facility's policy on Safe Lifting and Movement of Ressidents indicates mechanical lift should be used for any resident needing a two person assist.

Based upon record review and interview the facility failed to ensure that 1(R1) of 6 residents in the sample received the necessary assistance and services to prevent an accident. This failure resulted in a Right Mildly Displaced comminuted distal tibia and fibula fractures just above the ankle joint. Finding Include: R1 had been discharged from the facility when onsite visit was initiated on 2/29/2012. Review of R1's closed record 12/17/2011 Consultation record in part depicts the following: "patient is a [AGE] year old female, alert, orientation 0. The right ankle Xray revealed a valgus impacted bimalleolar ankle fracture with significant osteopenia present." The X-ray report 12/16/2011 of the Right Ankle denotes in part the following: "Mildly Displaced comminuted distal tibia and fibula fractures just above the ankle joint." E3 and E4 were the assigned CNA's (certified nurse aides) for R1 on 12/16/2011. R1 is completely dependently on staff for ADL's (activities of daily living) per MDS (minimum data set) and nursing care plan. E4 is no longer employed per E1 (administrator). E3 was interviewed on 2/29/11-10:30 am stated, "E4 that morning asked me to help her clean R1. When I touched R1's right foot, R1 cried out a lot. I asked E4 about it, and E4 responded, R1 always cries out. I didn't tell anyone R1 cried out. I took off R1 sock, R1 cried out, I cleaned R1 foot. R1 cried out and I put another sock on, and R1 cried out. R1 was crying out before R1 got in the (mechanical) lift, did not hit foot on the (mechanical) lift." On 3/1/2012-10:00 am, E5 (R1's charge nurse) interviewed, and signed a written statement. E5 stated,"Around lunch time, (12/16/2011) the niece of R1 told me R1's right ankle was swollen, and asked me to look at it. I went, R1 was in the lobby. I assessed it, touched it and it was warm to touch. R1 was showing facial grimaces like pain. I had the aides lay R1 in bed. I removed R1's sock, I called R1's doctor and the doctor ordered an X-ray. I asked the aides if they noticed it, one of them said they didn't notice it, but I do not remember who that was, because one helped the other with her. No one reported it before R1's niece got me." The facility provided the interview of R6 (roommate of R1) on 3/1/2012. R6 is no longer living at the facility per E1 (administrator). The interview of R6 denotes in part the following: "Upon interviewing R6 who is the roommate of R1, R6 stated that when the girls got R1 up this morning (referencing 12/16/11) in that lift, R1 hit her foot on the bar of the lift. R6 said no one did it on purpose, the girls said they were sorry. R1 said ouch when her foot was bumped...." E4 and E3 failed to notify facility staff when R 1 cried out in pain during the ADL care. Subsequently, services were not rendered until the family member of R1 notified E5.

Based on observations , close records and interviews the facility failed to manage pain control correctly for 2 of 4 sampled residents ,R2 and R10. R1 experienced respiratory complications and sent to the hospital. R1 was assess and identified as medically compromised with other medically co-morbidities was found in his bed unresponsive and transport to the hospital and found to have excessive dosages of [MEDICATION NAME] medications by the emergency room physician. R10 was observed with an [MEDICATION NAME] in place that was outdated (wrong dose) and requesting for pain medication because of a surgical site. Findings Include: Review of R2 admission records notes R2 is an [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of R2's nursing notes dated 7-4-10 at 5:00PM notes the following: resident noted to have altered mental status, skin was pale, slurred speech, difficult swallowing, and hand grasp equal. Responding to touch and pain. Eyes appear droopy.... E6 (staff nurse) stated on 10-8-10 she was the nurse to send R2 out to the hospital. E6 confirmed her assessment on 7-4-10 of R2. Review of the medical records from the hospital dated 7-4-10 notes R2 had one [MEDICATION NAME] remove by paramedics and anther [MEDICATION NAME] remove by the emergency room physician. Review of R2's physician order [REDACTED]. The pain medication was [MEDICATION NAME] 5% patch apply to back (local pain). This was to be applied at 6:00AM and taken off at 6:00PM on a daily bases. The second pain medication was [MEDICATION NAME] 40mg by mouth every 12 hours. The third pain medication was a [MEDICATION NAME] 25mcg [MEDICATION NAME] (on top of skin). Review of R2's medications administration records notes, (MAR) R2 received [MEDICATION NAME] 40mg on July, 1, 2, 3 and 4 of 2010. R2 was been administered [MEDICATION NAME] 5% for local pain on July 1, 2, 3 and 4 of 2010. R2 was also administered his scheduled order [MEDICATION NAME] 25mcg topically for pain on 7-4-10. Z1 (medical attending) stated on 10-8-10 that upon admission he was strongly against the amount of pain medication that R2 was receiving. Z1 stated that the family insisted that R2 continue his current regimen of pain medication. Reviews of Z1 physician order [REDACTED]. Further reviews of the clinical records, R2 had an outside medical appointment with another physician who ordered additional pain medications. Z1 stated on 10-8-10 that he ws not aware of any other pain medications were ordered by another physician. Z2 (psychologist) notes dated 7-1-10 notes the following: R2 was referred for consultation due to concerns about pain expression and possible addiction. R2 appears very lethargic and fatigue. R2 acknowledge long-standing history of [MEDICATION NAME] use following a back injury. R2 stated he rates the pain level at 4, on a scale of 1 to 10, (10 being the highest). R2 admitted to depression since the death of his wife, [AGE] years ago, has decease memory, concentration, mental tracking and appetite. R2 is positive for psychomotor lethargy and social isolation. Z2 ' s recommendations notes: 1). decrease depression by exploring bereavement of his (wife) , 2). provide pain management teaching by defocusing and increasing activity and, 3). Psychiatric involvement to address his affect (dementia) which could compromise pain expression. This assessment was done 3 days before R2 was transport to the hospital in a medically compromised emergency condition. Z2 stated on 10-8-10 confirm her approach on excessive use of pain medication is to de-focus and increase activity. Z2 also stated that a [DIAGNOSES REDACTED]. 2). Observations of R10 on 10-8-10 at 2:00PM on the medical unit. R10 was requesting medication for pain. Further observations of R10 in her room in her bed, R10 had on a [MEDICATION NAME] dated 10-4-10. Review of R10 admission records notes R10 is [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of R10 medications administration records notes the following: [MEDICATION NAME] DIS 25mcg/hour ( pain patch) every 72 hours, (3 days). R10's pain patch was on for 4 days, not 3 days as order. R10 was complaining of pain and requesting pain medication by the nursing staff her her right arm surgical repair. E 1( Director of nursing) on 10-8-10 stated an in-service to the nursing staff was done about pain management. Review of the facility's pain medication policy. It was incomplete. Z4 (Corporate Nurse) stated that the pain management policy is incomplete and the corporate office has not done it.