Every finding on record at Encore Village

Based on interview and record review the facility failed to ensure a safe environment during a transfer resulting in a fall and ensure fall prevention interventions were implemented for one of three residents (R1) reviewed for falls. Findings include:On 8/4/2026 at 11:30am R1 said that on 7/18/2026 that V3(Certified Nursing Assistant-CNA) was assisting him from the bed to the wheelchair, upon sitting on the side of the bed V3 adjusted the height of the bed up, so that I would not have far to stand up upon trying to stand my right leg gave out and I fell to the floor then V3 lowered the bed and called for assistance. On 8/5/2026 at 10:30am V3 said that on 7/18/2026 she was transferring R1 from the bed to the wheelchair and that she adjusted the bed slightly up so that he would not have far to stand, his feet were still flat to the floor as R1 started to stand his right leg gave out, R1 was sliding so I lowered the bed and assisted him to the floor then called for help.On 8/5/2026 at 11:30am V2(Assistant Director of Nursing-ADON) and this surveyor observed R1 sleeping, R1's bed was not lowest to the floor and the fall mats were against the wall. On 8/5/2026 at 11:35am, V2 said the bed should be lowest to the floor and fall mats should be down also. I expect the CNA staff to always use their gait belt. I expect the CNA staff to lock the bed wheels when transferring and not to adjust the bed during a transfer. A resident information document indicates R1 is [AGE] years old has a diagnosis of malignant neoplasm of the bone, unsteady gait and right leg pain, order summary report indicates on 6/22/2026 that R1 may be assessed for pain, an initial morse fall scale on 6/22/2026 scoring a 35 which indicate moderate risk for falling, a morse fall risk on 7/18/2026 with a score of 50 indicates a high risk for falling , a fall report on 7/18/2026 at 22:30 indicates the V3 was attempting a transfer and slightly elevated the bed to assist with standing as resident attempted to stand he unable to bear weight and began sliding and was lowered to the floor. A care plan that indicates intervention on 7/18/2026 ensures bed is in the appropriate lowest position for the patient and that the wheels are locked and may have floor mats while in bed. Facility Policy: 8/2024 Management of FallPolicy: The facility will identify and evaluate potential hazards and risk factors, establish care plans to address identified concerns, implement appropriate interventions, and routinely review and update these plans to minimize the risk of falls and related injuries. Procedure:6. Assess and monitor the residents' immediate environment to ensure effective management of potential hazards, including maintaining the bed in a position appropriate for safe transfers with wheels locked at all times, ensuring the call light and personal items are within reach, and maintaining a clutter-free space with adequate lighting.

Based on interview and record review, the facility failed to follow its advance directive/life sustaining policy by not having power of attorney implemented for a resident. This applies to 1 of 3 (R1) residents reviewed for advance directives in a sample of 3.The findings include: R1 was an [AGE] year-old male admitted on [DATE] having moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE] and with an admitting diagnosis including heart failure, atrial fibrillation, urinary retention, urinary tract infection (UTI), history of falling, and Benign Prostatic Hyperplasia. On 10/10/25 at 11:25 AM, V9 (Nurse Practitioner) stated, The daughter was making decision on R1. One-time R1 came back from the hospital, signing out Against Medical Advice (AMA) on Uber. The daughter said she was tired of him and asked why the facility couldn't call my fiance, who has the power of attorney. On 10/14/25 at 1:46 PM, V7 (Social Service) stated, I am not sure who was the power of attorney for R1. I will ask the administrator about the R1's POA.On 10/10/25 at 1:12PM, V6 (R1's son-in-law) stated, I am R1's power of attorney, and the facility didn't let me know about R1's condition until the day R1 passed away. I am not worried that they called V5 to notify R1 of the change in condition. They always contact V5; nobody informed me about R1's decline or about his multiple falls.On 10/14/25 at 2:00 PM, V1 (Administrator) stated, We never got any power of attorney (POA) paperwork. V5 is the primary contact, so we were contacting V5. It was a mistake that staff were documenting V6 as R1's POA. On 10/14/25 at 11:00 AM, V1 added, The social service has the sole responsibility to have the advance directive in place for our residents.R1's medical record did not reveal any paperwork designated in writing that V5 nor V6 as R1's Power of Attorney. A review of the facility provided advance directive/life sustaining treatment policy revised on 11/24 document: The Social Service Director and or designee will assess. Care plan and implement Advance Directives within 30 days after admission.DefinitionFor the purpose of this policy resident representative means a person appointed as a decisional representative that is either designated in writing by a resident to be his or her power of attorney or the resident's healthcare surrogate or guardian.

Based on interviews and record review, the facility failed to reconcile a residents' (R1) discharge medications with current prescription orders prior to discharging the resident. This failure affected two of three residents (R1, R3) reviewed for medications in the sample of three and resulted in several of R3's medications being found within R1's accompanying medications after discharging home.The findings include: On 08/20/2025, review of R1's Discharge summary dated [DATE] showed no documentation under sections for medication list, medication reconciliation, or medication review. On 08/20/2025, review of grievance/concern forms showed a concern for R1 dated 08/13/2025 that indicated V7 reported a medication mix-up to V2 (DON). Family concern documentation provided by V2 indicated that V7 contacted the facility on 08/13/2025 (day after R1's discharge) to report two medication bottles not prescribed to the resident were found among [R1's] discharge belongings. Documentation then indicated during the discharge process, while packing medications and cleaning the medication cart simultaneously, there was a likely mix-up due to two medication bags being in close proximity that may have resulted in a medication bottle intended for another resident being mistakenly placed in [R1's] discharge bag. On 08/20/2025 at 12:29 PM, V4 (Registered Nurse) said R1 came to the facility on [DATE] under respite (short-term) care and admitted with a plastic zip lock bag filled with her home medications that were within labeled pill bottles from her pharmacy. V4 added that R1's medications were stored in the medication cart within the plastic bag. V4 added that R1's medication list was inputted into her electronic medical record and her medications were removed from the appropriate pill bottles during her scheduled administration times. On 08/20/2025 at 12:34 PM, V4 said on the morning of 08/12/2025 around 8:30 AM, R1's daughter (V7- Family Member) arrived at the facility and quickly packed R1's belongings then informed V4 that she was taking R1 home. V4 said she indicated to V7 that she needed to review and reconcile with them R1's discharge orders and medications but V7 said she was in a hurry and just wanted to take R1 home with her bag of medications. V4 stated that she just took the bag of meds out of the cart and gave it to her daughter without checking any of the bottles. V4 then said that she did not reconcile R1's discharge medication orders with the medication bottles within the plastic bag prior to giving them to V7 which is part of the discharge process to ensure we are sending all the correct medications and doses home with the resident. On 08/20/2025 at 12:39 PM, V4 added that R3 had recently admitted to the facility with a similar plastic bag full of home medications that were also stored in the med cart but were not being used during R3's scheduled administration times because the facility utilized the medication bubble cards provided by the facility's pharmacy. V4 said both R1 and R3's bags of medications were stored next to each other in the med cart, and that she was unsure how or when some of R3's pill bottles were placed inside of R1's med bag because she had been off for several days prior to R1's day of discharge. V4 added that she did not clean out the med cart nor add R3's pill bottles to R1's medication bag upon her discharge. On 08/20/2025 at 1:09 PM, V2 (Director of Nursing) said that R1 was at the facility for respite care and came with her own meds which were stored in the med cart along with R3's bag of medications that were not in use and should have been returned to R3's family prior to this incident. V2 then said during the discharge process, the nurse should discuss with the resident and family their discharge plan and medication orders and should go through each individual medication with the resident/family to review any administration directions and provide education for each med. On 08/20/2025 at 1:15 PM, V2 said that V4 should have reconciled R1's medications on her own after V7's refusal and prior to giving V7 the bag of meds. V2 then said night shift nurses typically clean out the med carts and believed that two of [R3's] pill bottles had fallen out of his bag during cleaning and the unknown nurse mistakenly placed those pill bottles into R1's bag. V2 added that the unknown nurse who cleaned the med cart should have checked for the resident's name on the pill bottles before placing them into the appropriate bag. Nursing discharge summary policy dated 02/2024 reads in part: a discharge summary will be prepared for each resident discharged from the facility.At a minimum, the discharge summary will a summary of the resident's status to include a description but not limited to, the resident's drug therapy (all prescription and over-the-counter medications taken by the resident, including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident.

Based on interview and record review the facility failed to ensure a resident received their scheduled medication for 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 3. The findings include: A facility assessment done on 6/7/24 indicated R1 was cognitively intact. On 6/24/25 at 10:25 AM, R1 said the facility ran out of her tramadol (pain medication) causing her to miss a dose. R1's Medication Administration Record (MAR) for June 2024 showed R1 was to get tramadol scheduled four times a day and as needed. The MAR showed on 6/11/24 the 12:00 PM dose of tramadol was not given and to see the Progress Notes. R1's Progress Note entered on 6/11/24 at 1:01 PM showed tramadol was not available and the pharmacy would be delivering more after 2:00 PM. The progress note did not indicate tramadol was retrieved from the medication tower. R1's tramadol Controlled Substance Proof of Use sheet dated 6/7/24 showed after the 6/10/24 8:30 PM dose of tramadol was given, zero remaining tramadol was on hand. The next tramadol Controlled Substance Proof of Use sheet was dated 6/11/24 and the first documented dose was given on 6/11/24 at 5:00 PM. The controlled Substance Proof of Use sheets did not indicate the missing 6/11/24 12:00 PM dose of tramadol was removed from the medication tower. On 6/24/25 at 1:54 PM, V2 (Director of Nursing) said medications should be reordered when the supply gets low and the medications should be reordered early enough to ensure a dose is not missed. V2 added the facility has a medication tower that can be used to obtain medications. V2 said tramadol is kept in the medication tower. The facility's Physician Orders Policy (undated) showed proper channels of communication are used to ensure accurate delivery of medications and treatments to all residents. The nurse may reorder the medication when it is running low. While waiting for the pharmacy delivery, staff may obtain medications from the medication tower if it is available.

Based on interview and record review the facility failed to protect a resident from the misappropriation of resident property when a credit card was stolen from a resident's room for 1 of 2 residents (R2) reviewed for the misappropriation of resident property in the sample of 3. The findings include: The Final Incident Report dated 12/20/24 for R2 showed, Incident category: Resident misappropriation of property/theft. Summary of Incident: The resident is a long-term resident of the facility and is alert and oriented x 3 (person, time, & place); she is forgetful at times. On 12/17/24 the unit manager received an email from the police department detective. He was seeking assistance to identify a photo of the person within the email. The individual in the picture is presumed to be the individual who used the credit card of R2 at a store. The unit manager immediately reported to the interim administrator regarding the email received. The unit manager and ADON (Assistant Director of Nursing) reached out to POA (Power of Attorney), daughter of the resident. The POA stated that she realized that the credit card was not in the possession of the resident because she reviewed the monthly statement and that is when she saw a purchase made at a store. On 12/18/24 the unit manager was able to speak with the detective. The unit manager relayed to the detective that the individual in the picture did not work at the facility. The unit manager informed the detective of the CNA (Certified Nursing Assistant) who provided care to the resident during the same day when the credit card was used. The POA - daughter reached out to the credit card company was able to reverse the charges that were incurred. The POA then reached out to the police and filed a complaint. This is an ongoing investigation with the police. The facility will continue to assist law enforcement however we can. On 3/11/25 at 11:42 AM, V10 (R2's POA/daughter) stated, R2 wanted the credit card for incidentals. V10 stated she gets the credit card statements. V10 stated she reviewed the credit card statement and looked at it a few weeks later. She saw a charge dated 10/1/24 for a gaming system at a store for $500.00. V10 stated she notified the manager; she left a message. V10 stated she talked to R2 to see if she wanted the police involved and she did. V10 stated she contacted the police, and the detective has the dates. V10 stated the detective has been keeping in contact with the facility. V10 stated the police suspect that the person that used the credit card was someone that knew someone at the facility. They think an employee gave the card to someone else that used it. On 3/11/25 at 12:12 PM, V6 (Executive Director), V9 (Social Services), and V5 (Registered Nurse/Unit Manager) were presented information together and stated that theft should not occur at the facility. On 3/11/25 at 2:56 PM, R2 was sitting in a wheelchair in her room. R2's cell phone had a case around it with a card holder built into the case. R2 stated her credit card was stolen and had been in the wallet on her phone. R2 stated the police were contacted and thought that it was a friend of someone that worked at the facility that used the credit card. The credit card was used at a store for a large amount. R2 stated she would like to see someone arrested because stealing isn't right. The Face Sheet dated 3/11/25 for R2 showed diagnoses including congestive heart failure, pneumonia, acute respiratory failure with hypoxia, atrial fibrillation, chronic obstructive pulmonary disease, dysphagia, type 2 diabetes mellitus, colostomy, retention of urine, polyneuropathy, transient ischemic attack, insomnia, hypomagnesemia, hypokalemia, anorexia, macular degeneration, constipation, hyperlipidemia, dependence on supplemental oxygen, vitamin D deficiency, hyperparathyroidism, and hypothyroidism. The MDS (Minimum Data Set) dated 12/12/24 for R2 showed a BIMS (brief interview of mental status) score of 15 - no cognitive impairment. The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention policy (April 2021) showed, residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; c. consultants; d. volunteers; e. staff from other agencies; f. family members; g. legal representatives; h. friends; i. visitors; and/or j. any other individual.

Based on interview and record review the facility failed to report to the state surveying agency an allegation of misappropriation of resident property immediately, but not later than 24 hours when a credit card was stolen from a resident's room for 1 of 2 residents (R2) reviewed for the misappropriation of resident property in the sample of 3. The findings include: The Social Service Note dated 11/19/24 at 9:30 AM for R2 showed, the social worker spoke with resident's daughter (V10) regarding the stolen credit card. V10 shares that the credit card has been reported as stolen, and a police report has been filed. V10 shares that the credit card was located in the resident's phone wallet. V10 reports that charges were made on the credit card on 10/1/24. Social worker filed a concern form and endorsed to the administrator. The facility did not have an Initial Incident Report dated 11/19/24. On 3/11/24 at 11:03 AM, V9 (Social Services) stated, she reported to V2 (previous Administrator) that a resident's credit card was missing in October 2024 when V10 (R2's POA - Power of Attorney/daughter) reported it to her. V9 stated V2 didn't follow up on reporting it so it was not investigated until December 2024. V9 stated the last administrator was overwhelmed. Anyone that is an administrator knows that this needs to be reported. V10 stated she documented about it in the resident's record. On 3/11/25 at 11:42 AM, V10 (R2's POA/daughter) stated, R2 wanted the credit card for incidentals. V10 stated she gets the credit card statements. V10 stated she reviewed the credit card statement and looked at it a few weeks later. She saw a charge dated 10/1/24 for a gaming system at a store for $500.00. V10 stated she notified the manager; she left a message. V10 stated she thought she reported it to the facility sometime in November 2025 after she had received and reviewed the credit card statement. V10 stated she talked to R2 to see if she wanted the police involved and she did. V10 stated she contacted the police, and the detective has the dates. V10 stated the detective has been keeping in contact with the facility. V10 stated the police suspect that the person that used the credit card was someone that knew someone at the facility. They think an employee gave the card to someone else that used it. On 3/11/25 at 12:12 PM, V6 (Executive Director), V9 (Social Services), and V5 (Registered Nurse/Unit Manager) presented information together and V6 stated when the administrator is made aware of an allegation it must be reported to state surveying agency immediately. V5 stated the day she found out about the stolen credit card was on 12/17/24 and that is the date she reported it. The facility's Initial Incident Report dated 12/17/24 for R2 showed, Incident category: Resident misappropriation of property/theft. Summary of incident: Today on 12/17/24 at approximately 2:15 PM, V5 (Registered Nurse/Unit Manager), reported receiving an email from the police asking for assistance in the case that was being investigated involving the resident, R2's stolen credit card. In the email there was an image of an individual at the store whom they believe was involved in the theft of the credit card. Investigation initiated and ongoing. The Face Sheet dated 3/11/25 for R2 showed diagnoses including congestive heart failure, pneumonia, acute respiratory failure with hypoxia, atrial fibrillation, chronic obstructive pulmonary disease, dysphagia, type 2 diabetes mellitus, colostomy, retention of urine, polyneuropathy, transient ischemic attack, insomnia, hypomagnesemia, hypokalemia, anorexia, macular degeneration, constipation, hyperlipidemia, dependence on supplemental oxygen, vitamin D deficiency, hyperparathyroidism, and hypothyroidism. The MDS (Minimum Data Set) dated 12/12/24 for R2 showed a BIMS (brief interview of mental status) score of 15 - no cognitive impairment. The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program (April 2021) showed, residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Investigate and report any allegations within timeframes required by federal requirements.

Based on interview and record review the facility failed to have evidence that an allegation of misappropriation of resident property was thoroughly investigated for 1 of 2 residents (R2) reviewed for the misappropriation of resident property in the sample of 3. The findings include: The facility's Initial Incident Report dated 12/17/24 for R2 showed, Incident category: Resident misappropriation of property/theft. Summary of incident: Today on 12/17/24 at approximately 2:15 PM, V5 (Registered Nurse/Unit Manager), reported receiving an email from the police asking for assistance in the case that was being investigated involving the resident, R2's stolen credit card. In the email there was an image of an individual at the store whom they believe was involved in the theft of the credit card. Investigation initiated and ongoing. The report was signed by V4 (Assistant Executive Director). The Final Incident Report dated 12/20/24 for R2 showed, Incident category: Resident misappropriation of property/theft. Summary of Incident: The resident is a long-term resident of the facility and is alert and oriented x 3 (person, time, & place); she is forgetful at times. On 12/17/24 the unit manager received an email from the police department detective. He was seeking assistance to identify a photo of the person within the email. The individual in the picture is presumed to be the individual who used the credit card of R2 at a store. The unit manager immediately reported to the interim administrator regarding the email received. The ADON (Assistant Director of Nursing), spoke with nursing staff, and staffing coordinator to assist identifying the person in the email photo. They were not able to match any nursing staff. The unit manager and ADON (Assistant Director of Nursing) reached out to POA (Power of Attorney), daughter of the resident. The POA stated that she realized that the credit card was not in the possession of the resident because she reviewed the monthly statement and that is when she saw a purchase made at a store. On 12/18/24 the unit manager was able to speak with the detective. The unit manager relayed to the detective that the individual in the picture did not work at the facility. The unit manager informed the detective of the CNA (Certified Nursing Assistant) who provided care to the resident during the same day when the credit card was used. The POA - daughter reached out to the credit card company was able to reverse the charges that were incurred. The POA then reached out to the police and filed a complaint. This is an ongoing investigation with the police. The facility will continue to assist law enforcement however we can. On 3/11/25 at 11:42 AM, V10 (R2's POA/daughter) stated, R2 wanted the credit card for incidentals. V10 stated she gets the credit card statements. V10 stated she reviewed the credit card statement and looked at it a few weeks later. She saw a charge dated 10/1/24 for a gaming system at a store for $500.00. V10 stated she notified the manager; she left a message. V10 stated she thought she reported it to the facility sometime in November 2025 after she had received and reviewed the credit card statement. V10 stated she talked to R2 to see if she wanted the police involved and she did. V10 stated she contacted the police, and the detective has the dates. V10 stated the detective has been keeping in contact with the facility. V10 stated the police suspect that the person that used the credit card was someone that knew someone at the facility. They think an employee gave the card to someone else that used it. On 3/11/25 at 12:12 PM, V6 (Executive Director) stated the administrator should have initiated an investigation and to protect residents' rights they need to ensure the investigation is completed. On 3/11/25 at 1:29 PM, V4 (Assistant Executive Director) stated V11 ADON (Assistant Director of Nursing) did the investigation for R2. V11 would have spoken to everyone and documented in the electronic medical record. V4 stated normally the internal documents and interviews are in the files. V4 stated staff should be interviewed and other residents in the area depending on what happened. V11 stated the interviews should be there for R2's credit card incident but they are not. On 3/11/25 at 1:35 PM, V11 (ADON) stated V5 (Registered Nurse/Unit Manager) did the investigation for R2 and the theft of the credit card. V11 stated it was brought to their attention when the police called to talk to V5. V11 stated she did not personally interview anyone and did not recall who made the report. On 3/11/25 at 2:25 PM, V5 RN (Registered Nurse/Unit Manager) stated she did not do the investigation for R2's credit card theft and was not involved in the interviews. V5 stated she did not talk to R2 about it. V5 stated the only person she talked to about it was V10 (R2's POA/daughter). The Face Sheet dated 3/11/25 for R2 showed diagnoses including congestive heart failure, pneumonia, acute respiratory failure with hypoxia, atrial fibrillation, chronic obstructive pulmonary disease, dysphagia, type 2 diabetes mellitus, colostomy, retention of urine, polyneuropathy, transient ischemic attack, insomnia, hypomagnesemia, hypokalemia, anorexia, macular degeneration, constipation, hyperlipidemia, dependence on supplemental oxygen, vitamin D deficiency, hyperparathyroidism, and hypothyroidism. The MDS (Minimum Data Set) dated 12/12/24 for R2 showed a BIMS (brief interview of mental status) score of 15 - no cognitive impairment. The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program (April 2021) showed, residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframes required by federal requirements.

Based on observation, interview and record review the facility failed to ensure a newly admitted resident on tube feeding was weighed weekly. This failure resulted in R125 losing 16.8 pounds (11.4% weight loss) in 18 days. The facility failed to monitor weights, assess residents who have had a significant weight loss and implement interventions to prevent further weight loss. This failure resulted in R20 losing 12.6 pounds (7.67% weight loss) in 1 month and R231 losing 10.2 pounds (6.6% weight loss) in 13 days. This applies to 3 of 5 residents (R20, R125 and R231) reviewed for nutrition in the sample of 26. The findings include: 1. R125's Face Sheet shows that he admitted to the facility on [DATE] with diagnoses of: severe protein-calorie malnutrition, gastrostomy, dysphagia and parkinsonism. R125's Physician's Order Sheet (POS) printed on 11/20/24 shows an order dated 10/24/24 for, Weekly weights x 8 weeks . The POS shows orders for NPO (nothing by mouth) and an order for enteral feeding. R125's Nutritional Risk assessment dated [DATE] shows, admitted with diagnosis of metabolic encephalopathy, osteomyelitis of left ankle and foot He is NPO d/t [due to] dysarthria and on new peg tub for enteral feeding .Wife denies any notable significant changes to weight in past month .at risk for unintended weight loss .dehydration pressure injury weight goal-weight will be maintained +/- 5% or gain by review Interventions: Monitor weight weekly for 8 weeks and then monthly or as indicated .Additional Comments: Will continue to monitor weight, TF (tube feeding) tolerance and intervene as needed. RD (Registered Dietitian) available for consult PRN (as needed). R125's Weights and Vitals Summary printed 11/20/24 shows a weight of 147.8 pounds on 10/24/24 and a weight of 131 lbs on 11/11/24 (11.4% weight loss in less than a month). There are no other documented weights between 10/24/24 and 11/11/24. On 11/20/24 at 9:22 AM, V4 (Registered Dietitian) said that all new admissions are weighed upon admission and then weekly to monitor for weight loss or gain. V4 said that any one who is triggered to be at high risk for weight loss have weights done weekly. V4 said that if a resident is on tube feeding, they are at high risk for weight loss and their weights should be closely monitored. V4 said that she saw R125 when he first arrived at the facility. V4 said that he was admitted with continuous tube feeding orders so she changed the rate and time frame so he did not have to be on continuous feedings but would still get the same amount of calories and nutrition. V4 said that R125 did not have any documented weights for some time and she is not sure why. V4 said that once R125 got a weight done, it showed a weight loss so she increased his tube feeding rate. V4 said that weekly weights would have helped identify a weight loss sooner so interventions could have been implemented to prevent further weight loss. The facility's Nutrition-Hydration-Weight-Assessment and Intervention Policy revised on 1/27/22 shows, The facility shall measure resident weights on admission, for the next two days, and weekly for 4 weeks thereafter .Weights are recorded in the resident's medical record .Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, the dietitian shall be notified, and the notification documented in the resident's medical record. The dietitian will respond within 24 hours of notification .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month-5% weight loss is significant; greater than 5% is severe . 33760 2. On 11/19/2 at 10:41 AM, R20 was being served breakfast. Both V9 and V10 (Certified Nursing Assistants-CNA) said R20 is a total feed so she was served at a later time during meals. Review of R20's weights shows: 9/3/2024-169.0 pounds (lbs.), 10/1/2024-170.1 lbs and on 11/14/2024-157.5 lbs. R20's weights show that she had a significant weight loss of 12.6 pounds (7.67%) in 1 month. R20 had no nutritional assessments or nutritional intervention related to this significant weight loss. On 11/20/24 at 9:13 AM, V4 (Dietitian) said R20 was weighed last on 11/6/24 and her weight was totally different from her usual weight. V4 said on 11/7/24 she requested a reweigh. On 11/14/24, R20's reweigh was 157.5 lbs. V4 said she did not know why the reweigh was not done until after a week. V4 said she was also not made aware of R20's reweight results sooner. V4 said when she entered R20's latest weight of 157.5 lbs, it did not trigger a significant weight loss until it was brought to her attention by this surveyor. V14 said she will do nutritional assessments and recommendations today. 34117 3. R231's face sheet shows she is an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with diagnoses including fracture of left pubis, type 2 diabetes, unspecified dementia, muscle weakness, hypertension, osteoporosis, and history of failing. R231's Weight Report for November documents: 11/6/24 -154.5 lbs, 11/7/24 - 147.5 lbs and on 11/19/24 - 144.3 lbs. R231's weights show that she had a significant weight loss of 10.2 pounds (6.6%) in 13 days. R231's Mini Nutritional assessment dated [DATE] shows a score of 6 indicating she is malnourished. R231's Diet card shows a regular diet, all meals milk only; no juice or coffee. R231's Nutrition Risk assessment dated [DATE] documents she is on a regular diet, requires set assistance, partial moderate assistance with feeding, fair appetite, (R231) reports not eating very much, (V8 R231's spouse) reported her intake of about 30%, she reported not being able to choose foods. (R231) is at risk for unintended weight loss due to malnourished score of 6, poor appetite, bed bound, and assistance with feeding. On 11/18/24 at 1:12 PM, R231 was lying in her bed, she said I'm hungry. V8 was in the room and said lunch usually comes between 1:00 PM to 1:30 PM. At 1:30 PM, the noon meal was not delivered. At 1:48 PM, V8 was upset R231's noon meal was not delivered yet. He said my wife is hungry. On 11/19/24 at 9:51 AM, R231 was in her room eating her breakfast meal. Her meal ticket said milk with all meals. There was no milk on her tray, she had a cup of orange juice and coffee. V13 (Unit Manager) entered the room and said to R231, where is V7 (Certified Nursing Assistant) she was in here helping you. On 11/19/24 at 12:56 PM, V7 (CNA) said R231 is alert and forgetful, she is two person transfer with a mechanical lift. She needs to be set up for meals, this morning she encouraged her to feed herself and she was able to do it so she left the room. R231 told her she was hungry and wanted her lunch before therapy. At 1:00 PM, therapy arrived to R231's room she had not been served lunch yet. On 11/20/24 at 12:35 PM, V4 (Dietitian) said R231 came in with pelvic fracture and was sent out to the hospital and readmitted . Staff should weigh residents on admit and re-admission. V8 reported to her R231's normal weight is about 150 pounds. R231 was not weighed when she was readmitted on [DATE], her initial weight on admission was 154 pounds we re-weighed her a day later and she was 147 pounds. On 11/19/24 her weight was 144 lbs. She has lost weight and she recommended nutritional shakes and protein in between meals. If a resident is voicing they are hungry staff should notify us so we can accommodate an earlier meal. She did not know R231 was requesting her meal to be delivered before therapy.

Based on observation, interview and record review the facility failed to ensure a resident's legs were properly supported while sitting in her wheelchair for 1 of 26 residents (R57) reviewed for accommodation of need in the sample of 26. The findings include: R57's Face Sheet shows she has diagnoses of: history of venous thrombosis and embolism, back pain, scoliosis, osteoporosis, history of a fracture and left foot pain. R57's Vitals Summary Report shows that she is 60 inches tall. On 11/18/24 at 11:39 AM, R57 was sitting in her wheelchair in her room. R57's feet were hanging approximately 6 inches from the floor and R57 did not have any leg rests on her wheelchair. R57's legs were reddish purple in color. On 11/19/24 at 1:00 PM, R57 said that if she puts her feet on the bar of the tray table, she is comfortable but if her legs are just hanging, it is not very comfortable. R57 said that she is about five feet tall. On 11/19/24 at 1:42 PM, V20 (Therapy Director) said that for proper positioning in a wheelchair, a resident's feet should be either flat on the ground or placed on foot rests that are adjusted to ensure that their feet are supported. V20 said that the legs should be supported to prevent swelling or pressure on the back of the legs. V20 said that R57 does not self propel her wheelchair so she should have leg rest on her wheelchair when she is sitting in it. V20 went to R57's room and was only able to find two left-sided foot rests. The facility's Resident Rights and Dignity - Accommodation of Needs Policy revised on 12/8/21 shows, The facility's actions of the environment and its' associates are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well being. The resident's individual needs a preferences will be accommodated to the extent possible.

Based on interview and record review the facility failed to ensure a resident's advanced directives were discussed and implemented upon admission for 1 of 26 residents (R282) reviewed for advanced directives in the sample of 26. The findings include: R282's Face Sheet shows that he admitted to the facility on [DATE]. The Face Sheet shows that his original admission was 4/8/22. R282's Electronic Medical Record (EMR) has a POLST (Physician Orders for Life Sustaining Treatment) Form that shows that R282 does not want resuscitation. This form was uploaded into R282's EMR on 10/21/2024. R282's Physician's Order Sheet Printed on 11/20/24 shows an order dated 11/15/24 for R282 to be a full code (attempt resuscitation). R282's EMR does not document that social services discussed R282's advanced directives with him or his power of attorney prior to 11/20/24. R282's Social Services Note dated 11/20/24 shows, Verified POLST Form with resident and spouse, both resident and spouse confirm request for DNR (Do Not Resuscitate). On 11/20/24 at 1:00 PM, V2 (Director of Nursing) said that a resident's advanced directives are discussed by the nurse upon admission. V2 said that residents are a full code until they receive a valid POLST form. V2 said that if a resident has a valid POLST form on file, the facility staff should follow those directives unless the resident has other wishes and the discussion should be documented in their medical record and verified with the physician. V2 said that social services follows up with new residents the following day to ensure that their advanced directives are correct. V2 said that she does not know why R282's POLST Form directives were not implemented or why social services did not follow up with him the day after his admission. The facility's Emergency-First Aid-Do Not Resuscitate Order Policy revised 10/18/22 shows, DNR/POLST orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR/POLST order.

Based on observation, interview and record review the facility failed to ensure residents who require staff assistance with ADLs (Activities of Daily Living) received showers/baths. This applies to 2 of 26 (R58, R39) residents reviewed for activities of daily living in the sample of 26. The findings include: 1. R58's face sheet shows she is a [AGE] year old female including Parkinson's disease, congestive heart failure, contracture of the right hand, osteoarthritis, history of falls, atrial flutter, chronic kidney disease, and gout. R58's Minimum Data Set assessment dated [DATE] shows she is cognitively intact, has no rejection of cares, and requires substantial/maximum assistance with showers/bathing. On 11/18/24 at 10:26 AM, R58 was sitting in her wheelchair in her room. Her right hand was clenched and and she had tremors to her left hand. She said she is supposed to get showers twice a week on Wednesday and Saturday on PM shift. She said the last time she had a shower was a couple of weeks ago, when she asks the staff for her shower their response is we are short handed and alot of them are agency staff. On 11/19/24 at 9:07 AM, R58 said she was not offered a shower on Saturday. This surveyor located the shower book at the common area on the Gingko Unit. The shower schedule book showed R58's last documented shower was 11/2/24 ( 17 days ago) and 10/16/24 she received a bed bath. (There were no other showers/baths recorded on the sheet). On 11/19/24 at 12:56 PM, V7 (Certified Nursing Assistant-CNA) said R58 is alert and oriented, she complains about agency staff not providing cares. Residents should receive showers twice a week, staff document in the electronic health record (EHR) and the shower sheet with the nurse signing off the resident received their shower. Residents have reported they do not receive their showers by agency staff on the 2nd shift. On 11/20/24 at 10:35 AM, V2 (Director of Nursing) said staff should chart resident showers in the EHR. The shower sheet is the worksheet that should be filled out by the CNA and signed off by the nurse. The charting in the EHR is the documentation. The Gingko Unit Shower Sheet Schedule shows R58's showers are scheduled for Wednesday and Saturday on the PM shift. R58's Shower/Bath report provided on 11/20/24 shows there were no showers documented for 30 days. R58's Shower Sheet forms provided on 11/19/24 shows a bed bath was given on 10/16/24, 11/2/24 a shower was documented given and a new recorded shower date of 11/16/24 refused during AM shift. 34490 2. On 11/18/24 at 11:45 AM, R39 was laying in bed. There was a strong urine odor present in the room. R39's hair appeared greasy. On 11/18/24 at 11:45 AM, R39 said that she is supposed to get showers every Tuesday and Friday but she has not had a shower in over a week. On 11/18/24 the unit's shower binder was reviewed. The binder shows that R39 is to receive showers on the PM shift on Tuesday and Fridays. The last documented shower for R39 was from 11/8/24. There were no documented showers for 11/12 or 11/15. R39's Bathing Task shows that she received a shower on 11/8/24 and no additional showers or bed/towel baths until 11/18/24. No refusals of showers were documented between 11/8/24 and 11/18/24. R39's Kardex Report shows, Bathing/Showering: [R39] needs assistance with bathing. On 11/19/24 at 1:27 PM, V19 (Certified Nursing Assistant) said that showers are provided to residents twice a week. V19 said that all showers are charted in the computer and on the shower sheet in the binder. The facility's Personal Care-ADL Support Policy shows, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care)

Based on observation, interview and record review the facility failed to ensure a gait belt was used during a transfer and failed to ensure interventions were added to a resident's plan of care after a fall to prevent additional falls for 2 of 26 residents (R39 and R110) reviewed for safety in the sample of 26. The findings include: 1. On 11/18/24 at 11:48 AM, V23, Certified Nursing Assistant (CNA) transferred R39 to the toilet using a gait belt. V23 removed the gait belt to provide care and change R39's shirt. After R39 used the toilet, V23 directed R39 to stand and hold onto the bar on the wall. V23 did not reapply the gait belt before directing R39 to stand up. While V23 was providing perineal care, R39 stated, I can't hold on much longer .I'm getting heavy. V23 then pulled up R39's incontinence brief and pants up and assisted her to sit back into her wheelchair. On 11/19/24 at 1:27 PM, V19 (CNA) said that gait belts should be used on all resident transfers for the resident's safety. R39's (Resident Care Informaiton) Report shows that she needs assistance of one staff member for transfers. The facility's Positioning/Moving-Safe Resident Handling Policy revised on 12/29/21 shows, Gait belt usage-Gait belt usage is recommended for a 1 person transfers with the exception of bed mobility and/or medical contraindications. 33760 2. R110's Physician Order Sheet dated 11/24 shows R110 has diagnoses of senile degeneration of brain, dementia, weakness, anxiety and depression. R110's facility assessment dated [DATE] shows R110 has severe cognitive impairment. BIMS (Brief Interview of Mental Status) of 3. R110's fall risk assessment shows R110 is high risk for falls. Review of R110's fall incident reports shows: -9/27/24 (V14, Restorative Registered Nurse/RN ) was assisting (R110) to her recliner from her wheelchair. As resident was screaming to go back to her recliner while transferring with 1 staff assist, (R110)'s knee buckled and was lowered slowly to the floor. -10/4/24 (R110) was being transferred (with 1 assist). (R110) became weak and was lowered to the floor. (R110) sustained injury after the fall including left knee skin tear, and abrasion to left rear back. On 11/20/24 at 11:20 AM, V14 (Restorative RN) said on 9/27/24, R110 was having behaviors, yelling and screaming. R110 was wanting to be transferred to her recliner. V14 said she applied a gait belt but R110 was already resistive and was having behaviors. Two (2) person assist should have been safer for R110 due to her behaviors. V14 said after the 2nd fall incident (10/4/24) of R110 again being lowered to the floor, was when she adjusted R110's transfer assessment to use 2 staff assist or sit to stand assist when needed. (No fall intervention was done after the 9/27 fall.) R110's Transfer Mobility assessment dated [DATE] shows, .needed maximum assist staff to stand up r/t [related to] weakness, poor trunk support, unsteady standing balance .May use sit to stand lift PRN [as needed].

Based on observation, interview and record review the facility failed to ensure a resident was administered oxygen using a high flow nasal cannula for 1 of 6 residents (R281) reviewed for oxygen administration in the sample of 26. The findings include: R281's Physician's Order Sheet printed on 11/20/24 shows diagnoses of: dependence on supplemental oxygen, hypertension, chronic kidney disease, chest pain, acute respiratory failure with hypercapnia and hypoxia, pulmonary hypertension, pulmonary fibrosis, chronic obstructive pulmonary disease and myocardial infarction. R281's oxygen order dated 11/5/24 shows, Oxygen: 7 liters a. continuous . On 11/18/24 at 9:45 AM, R281 was sitting in his chair in his room with oxygen on. R281's oxygen tubing and cannula were clear and appeared to be regular flow oxygen cannula. R281's oxygen tubing was plugged into an oxygen concentrator set at 7 liters of oxygen. On 11/19/24 at 1:05 PM, R281 was sitting in his room with his oxygen on and had the same clear tubing. R281's oxygen concentrator was still set at 7 liters. On 11/19/24 at 2:24 PM, V21 (Respiratory Therapist) said that any resident that is on more than 5 liters of oxygen should have a high flow nasal cannula and they are green in color. At 2:43 PM, V21 said that she just checked R281's oxygen cannula and it was not a high flow oxygen cannula but should be. V21 said that the difference between a regular oxygen cannula and the high flow cannula is the bore size of the cannula. V21 said that the high flow cannula is large so it is able to administer the larger amount of oxygen. The facility's Respiratory and Pulmonary Conditions-Oxygen Administration Policy revised on 1/25/24 does not show when a high flow oxygen cannula should be used for residents.

Based on observation, interview and record review the facility failed to ensure staff administered medications to a resident and not leave them on the bedside table. This applies to 1 of 26 residents (R15) reviewed for pharmacy services in the sample of 26. The findings include: R15's face sheet shows she is a [AGE] year old female with diagnoses including congestive heart failure (CHF), chronic pulmonary embolism, type 2 diabetes, asthma, chronic kidney disease, macular degeneration, dyshpagia, anxiety, peripheral vascular disease, hypertension, and GERD (Gastroesophageal reflux disease). On 11/18/24 at 10:20 AM, R15 was in her room sitting in her wheelchair. A cup of crushed medications in water were on her bedside table. R15 said those are my medications, the nurse crushes them because they are hard for me to swallow. At 10:35 AM, this surveyor left the room, R15's cup of medications remained at the bedside table. On 11/20/24 at 10:47 AM, V2 (Director of Nursing) said nursing should not leave medications at the bedside table. They should watch the resident take the medications before leaving the room. R15 does not have an assessment to self administer her own medications. R15's Physician Order Sheets dated November 2024 shows orders including Bumex 2 mg (milligrams) in the morning for CHF, Hydralazine 100 mg three time a day for hypertension, Losartan Potassium 25 mg daily for hypertension, Monteluksat Sodium 10 mg daily for asthma, Ocular Vitamins 2 tablets daily, Senna-Docusate Sodium 8.6-50 mg two tablets for constipation twice a day, and Sprionolactone 25 mg daily for CHF, Sucralfate tablet 1 GM (gram) twice a day. R15's Medication Self-Administration Safety Screen dated 11/19/24 shows deep sea saline nasal spray is the only medication listed to self administer.

Based on observation, interview and record review the facility failed to ensure a resident was free from a significant medication error. This applies to 1 of 26 residents (R58) reviewed for medications administration in the sample of 26. The findings include: R58's face sheet shows she is a [AGE] year old female including Parkinson's disease, congestive heart failure, contracture right hand, osteoarthritis, history of falls, atrial flutter, chronic kidney disease, and gout. On 11/18/24 at 10:26 AM, R58 was sitting in her wheelchair in her room. Her left hand was shaking. She said she takes Carbidopa a medication for her Parkinson's disease in the morning, and is suppose to get her 2nd dose at 11:00 AM and sometimes she doesn't get her medication till 2:00 PM. On 11/19/24 at 9:07 AM, R58 said yesterday she did not get her medication for her Parkinson's on time, it was late. On 11/20/24 at 10:47 AM, V2 (Director of Nursing) said nursing should follow the five rights when administering medication including the right person, right time, right dose, right route and right drug. V2 said she followed up with R58's nurse V6 (Licensed Practical Nurse/LPN-Agency) about the medication being late. V6 reported R58 was in the dining room when the medication was scheduled at 11:00 AM. V2 said lunch is at 12:00 PM for residents in the dining room. It's important to ensure residents received their medication at the scheduled time. R58 has Parkinson's and if she does not receive her medication at the scheduled time it can affect her movements causing increased stiffness. R58's Physician Order Sheets dated November 2024 shows orders for Carbidopa-Levodopa 25-100 mg (milligrams) give two tablets three times a day. R58's Medication Administration Audit Report provided on 11/20/24 shows orders at 11:00 AM to administer Carbidopa-Levodopa. R58's administration time recorded at 1:47 PM (approximately three hours later). The facility's Medication Administration Policy and Procedure revised 2022 states, . medications are administered in a safe and timely manner, and as prescribed .medications are administered in accordance with prescriber orders, including any required time frame .

Based on observation, interview, and record review the facility failed to ensure medications were securely stored for 1 of 26 residents (R121) reviewed for medication storage in the sample of 26. The findings include: On 11/19/24 at 10:41 AM, R121 was in his room sitting in a chair. On the bedside table was a fluticasone-salmeterol respiratory inhaler and an azelastine nasal decongestant spray. R121 said the medications are kept on the bedside table. R121's Order Summary Report printed on 11/19/24 showed an order for fluticasone-salmeterol inhaler to be given two times a day. The same document showed an order for azelastine nasal decongestant spray to be given two times a day. On 11/19/24 at 10:45 AM, V22 (Licensed Practical Nurse- LPN) said R121 keeps the inhaler and nasal spray on the bedside table. V22 said R121 needed to be reminded on how to use the medications. V22 explained that R121 will forget to hold his breath when using the inhaler. On 11/20/24 at 11:53 AM, V15 (LPN) said medications are not left in a resident's bedside table because medications needs to be secured. V15 added that medication sitting on a bedside table are not secured. V15 said there are confused residents and you never know if a resident wanders into another resident room also the medication could be misplaced. On 11/19/24 at 11:01 AM, V2 (Director of Nursing) said for a resident to keep medications in their room there would need to be an assessment done. V2 said the assessment could be found in the assessment section of the resident's electronic medical record. On 11/19/24 at 11:05 AM, there was no assessment in R121's electronic medical record for R121 to keep medications at the bedside. The facility's Medication Storage policy with a reviewed date of 10/15/24 showed medications used in the facility are stored in a locked compartment. The facility's Medication Self Administration policy with a reviewed date of 10/15/24 showed a resident's ability to safely and securely store the medication is a factor when determining whether self administration of medication is appropriate. The same policy showed self administered medications are stored in a safe and secure place, which is not accessible by other residents.

Based on observation, interview and record review the facility staff failed to wash their hands and change their gloves to prevent the spread of infection and failed to ensure staff donned all applicable Personal Protective Equipment for a resident with Enhanced Barrier Precautions (EBP) for 2 of 26 residents (R20 and R12) reviewed for infection control in the sample of 26. The findings include: 1. On 11/18/24 at 10:27 AM, V9 and V10 (both Certified Nursing Assistants- CNAs) provided incontinence care to R20. R20 had a bowel movement. V10 provided incontinence care to R20. Wearing the same soiled gloves and without washing her hands, V10 applied a new incontinent pad, turned R20 side to side to put clothes on. Then R20 was transferred to her wheelchair using a mechanical stand lift, V10 continued to touched multiple surfaces, adjusting R20 in the mechanical lift and positioning V10 in her wheelchair. After doing all these tasks was when she removed her gloves and washed her hands. On 11/20/24 at 8:30 AM, V11 (Registered Nurse-RN) said staff should wash their hands and change their gloves when completing a dirty tasks and going to clean tasks to prevent cross contamination. The facility policy on Hand Hygiene dated 8/30/23 shows, .Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. 2. On 11/19/24 at 9:10 AM, a sign posted outside of R12's door showed, - Enhanced Barrier Precautions. V12 (Wound Nurse) donned gloves but did not wear a gown when he provided wound treatment to R12's sacral wound. At 12:10 PM, V2 (Director of Nursing) said staff will be reeducated again regarding EBP-wearing gloves and gown for high contact care like wound care. The facility policy on Enhanced Barrier Precautions (EBP) showed EBP, is an approach of targeted gown and gloves use during high contact resident care activities designed to reduce transmission of MDRO (multi-drug resistant organisms) and other pathogens.

Based on observation, interview, and record review the facility staff failed to ensure residents who required staff assistance with Activities of Daily Living (ADLs) received timely incontinence care for 2 of 4 residents (R2, R1) reviewed for ADLs in the sample of 9. The findings include: 1. R2's care plan dated 9/23/24 showed R2 required staff assistance with toileting and transferring. R2's resident assessment dated [DATE] showed R2 was frequently incontinent of urine and stool. On 10/31/24 at 8:44 AM, R2 was asleep in bed. A strong odor of urine was noted in her room. On 10/31/24 at 9:15 AM, R2 was awake, lying in bed. R2 stated, No one has come in yet this morning. I was last changed (provided incontinence care) late last night. The urine odor remained in R2's room. On 10/31/24 at 9:17 AM, V5 Certified Nursing Assistant (CNA) entered R2's room to provide cares. V5 (CNA) stated she had not toileted or provided incontinence care to R2 yet during her shift. As V5 (CNA) removed R2's incontinence brief, V5 stated, She's pretty wet. R2's brief was saturated with urine. Urine had leaked out of R2's brief, onto her shirt, pants, and bedding. 2. R1's care plan dated 10/22/24 showed R1 required staff assistant with toileting. The care plan showed R1 was frequently incontinent of urine and stool. On 10/31/24 at 8:40 AM, R1 was seated in a wheelchair in her room. R1 wore a gown. A urine odor was noted in her room. R1 stated staff got her up around 8 AM that morning, but did not toilet her or change her incontinence brief. R1 said, I wear a diaper. I think I am wet right now. When R1 was asked why staff didn't change her brief when they got her out of bed, R1 stated, I don't know. R1 denied refusing to be toileted that morning or refusing to have her incontinence brief changed. On 10/31/24 at 9:16 AM, R1 remained seated in her wheelchair, eating breakfast in her room. On 10/31/24 at 10:19 AM, R1 had finished eating breakfast. V6 (CNA) entered R1's room to provide cares. V6 (CNA) transferred R1 to the toilet. R1's incontinence brief was saturated with urine. R1's buttocks were bright pink. Urine had leaked out of R1's brief onto the pad on her wheelchair. V6 (CNA) was asked why R1 was not toileted upon getting her out of bed that morning. V6 stated, She refused this morning. R1 immediately turned to V6 and stated, I most certainly did not! On 10/31/24 at 9:59 AM, V7 (Licensed Practical Nurse) stated toileting and/or incontinence care should be provided to residents every two hours and as needed. The facility's Urinary Continence and Incontinence-Assessment and Management policy dated 8/2022 showed, The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence .

Based on observation, interview and record review the facility failed to assist a resident with eating and failed to ensure a nutritional intervention was implemented for a resident with significant weight loss. This failure resulted in R4 sustaining significant weight loss. These failures apply to 1 of 4 residents (R4) reviewed for weight loss in the sample of 9. The findings include: R4's Physician Order Sheet (POS) showed R4 had diagnoses of Alzheimer's Disease (AD), dementia and diabetes. R4's careplan initiated on 11/22/23 showed (R4) is at nutritional risk related to score of 5 (malnourished), inadequate oral intake, significant weight loss, low BMI .confusion, delusions, AD, dementia . With intervention to include: provide nourishments: house shake 8 ounces (oz) BID (Twice a Day) with lunch and dinner. Provide supervision, encouragement/cueing, and necessary assistance at meal time and between meals with food and fluids. R4's weight report showed: 10/2/24-115.8 lbs, 6.2 % weight loss from 9/3/24 123.5 (1 month 6.2% weight loss) 10/17/24- 118 lbs, 13.3% weight loss from 135.9 lbs last 5/2/24. (6 months 13.3% weight loss) 10/10/24-115.8 lbs, 14.8% weight loss from 135.9 lbs last 5/2/24. R4's Nutritional Risk assessment dated [DATE] showed, most recent weight 118.0 pounds (lbs). Weight trend for the last 6 months-weight loss. Significant weight loss x 1/3/6 months. That is most likely related to decreased oral intake past month. Goal for weight maintenance or gradual regain. Added house shake 8 oz to lunch/dinner to increase kcal/proteins intake and prevent further weight loss and promote weight re-gain. On 10/31/24 at 8:30 AM, R4 was in the dining room with her eyes closed. Her breakfast food was in front of her untouched. R4's breakfast consisted of scrambled eggs, pancakes and sausage. Staff were in and out in the dining room. There was no staff assisting or giving cues for R4 to eat. At 8:55 AM, R4 was wheeled out from the dining room and was placed in a table by the nurses station. V9 (Certified Nursing Assistant/CNA) said R4 did not eat her breakfast. R4 only eats a PBJ sandwich which will be served to R4 at lunch. On 10/31/24 at 12:45 PM, R4 was in the dining room for lunch eating her PBJ. There was a cup half full with water. There was no house shake noted with R4's lunch meal. R4's meal card showed- 8 ounces of mighty shake to be provided for lunch and dinner. There was no mighty shake provided to R4. On 10/31/24 at 1 PM, this surveyor clarified with V8 (R4's Nurse-Registered Nurse/RN) if R4 was to receive a mighty shake. V8 said R4 was supposed to get a house shake (mighty shake) provided by the kitchen at lunch due to R4's weight loss. On 10/31/24, V12, V17 and V18 (all Dining room servers) said they were not aware that R4 was supposed to receive shakes from the kitchen for lunch and confirmed none of them served R4's mighty shake for lunch. On 10/31/24 at 1:16 PM, V16 (Dietary Director) said R4's house shakes (mighty shake) was supposed to be provided by the kitchen and nursing documents when the resident takes the house shakes. V16 said the dietary servers did not give R4's shake at lunch. V16 said supplements (house shakes) are important for R4 since R4 already had lost a significant amount of weight. On 10/31/24 at 2:50 PM, V4 (Assistant Director of Nursing) said R4 was just reweighed and R4 continues to loss weight. R4's latest weight was 115 lbs which showed an additional 3 lb weight loss for R4, from 118 lbs (10/17/24) to today (10/31/24.)

Based on observation, interview and record review the facility failed to report adverse side effects immediately, failed to monitor the use of psychotropic medications, and failed to carry out the orders to hold medication for a resident showing signs of adverse effects of excessive drowsiness. This failure resulted in R1 being sent out to the hospital for evaluation for stroke like symptoms. This applies to 1 of 3 residents (R1) reviewed or unnecessary medications in the sample of 5. The findings include: R1's face sheet shows she is [AGE] year-old female with diagnosis including somnolence (excessive drowsiness 8/15/24), altered mental status (8/15/24), unspecified dementia with other behavioral disturbance, heart disease, delusional disorder, anxiety disorder, unspecified hearing loss, vascular dementia with psychotic disturbance, mood (affective) disorder, and glaucoma. R1's hospital Records dated 8/15/24 documents [AGE] year-old female with a history of vascular dementia and behavioral disturbances presents with acute encephalopathy and lethargy likely suspect due to polypharmacy. R1's hospital discharge medication list dated 8/16/24 shows a decrease dose in her psychotropic medications including Depakote 125 mg (milligrams) two capsules three times a day and Seroquel 50 mg twice a day. On 8/22/24 at 9:19 AM, R1 was observed in her lying in bed. R1 was yelling and calling out from her room. V7 (Registered Nurse/RN) entered the room to assist R1, using the communication board to ask R1 what she needed. R1 was not able to verbally express her needs to V7. R1 was on the call light frequently and yelling when staff left the room. At 9:54 AM, V9 and V10 (Certified Nursing Assistant's-CNA's) provided care to R1 including incontinence care and transferring her from the bed to the wheelchair using a mechanical lift. R1 did not display behaviors of aggression, combativeness, and was compliant with all cares. On 8/22/24 at 9:38 AM, V7 (RN) said R1 has behaviors of combativeness and agitation. She was hospitalized in June and sent to behavioral health. She had a change in her psychotropic medications due to lethargy. She has been okay since her dose was decreased. She still has some behaviors of yelling out and screaming, but is more awake. If a resident is showing adverse effects from the medication, nursing should hold the medication and notify the physician. On 8/26/24 at 8:57 AM, V5 (Unit Manager) said R1 is alert, confused, and has behaviors of crying, screaming, restlessness, agitation, and combative during cares. Lately she has periods of sleepiness in the late morning towards noon, after lunch she is more awake. She has difficulty expressing her needs. On 8/15/2, V16 (R1'sdaughter) came to visit and was upset how R1 was sleepy, difficult to arouse, and drooling. V16 was concerned her mom had a stroke. She explained to R1's daughter, V15 (Psych Nurse Practitioner) assessed R1 yesterday and there were new orders to hold the psychotropic medications (Seroquel 100 mg and Clonazepam 0.5 mg) if R1 was lethargic. She went in the room and called out R1's name. R1 opened her eyes but could not keep them open. R1 usually feeds herself; that day she needed assisting with meals. R1 was receiving three psychotropic medications scheduled three times a day including Depakote 375 mg, Seroquel 100 mg, and Clonazepam 0.5 mg. R1 was hospitalized for behaviors in mid-June and returned to the facility on [DATE]rd with increased doses of her psychotropic medications. R1 was sent out to the hospital for evaluation for stroke symptoms and CT's showed negative for a stroke. Psychotropics can cause sleepiness and R1 was not tolerating the doses of the psychotropic medications. If a resident is showing signs of adverse effects, nursing should hold the dose and notify the physician on onset of the changes. On 8/26/24 at 9:32 AM, V4 (RN Agency) said she was R1's nurse on 8/15/24. She is an agency nurse, and it was her first time caring for R1. Around lunch, a lady V16 (R1'sdaughter) came up to me and asked if she was R1's nurse and to come to the room. When she went to R1's room. R1's daughter was upset and crying, she said look at her, this is not my mother. R1 was sedated and drooling on herself, she was not able to eat because she was knocked out. The night nurse reported if R1 is too sedated to hold the antipsychotic medication. When she looked at the medications R1 was scheduled to receive, Depakote 375 mg, clonazepam 0.5 mg and Seroquel 100 mg three times a day. She was thinking why is R1 on so much medication. She gave what was scheduled, I have nothing to base it off, I felt terrible I gave the medications too. She questioned it, but she did not know the resident. R1's daughter requested to have her sent out to the hospital. She gave the morning dose and said she could not recall if she gave the afternoon dose, If it was scheduled I must have given the medications to her, I could have given the medications. On 8/26/24 at 1:15 PM, V2 (Director of Nursing) said staff should be monitoring the resident for side effects of psychotropic medications. Increased sleepiness is the first side effect of these medications. Nursing should hold the medication and notify the physician immediately. She confirmed the order to hold the medication did not reflect on R1's Medication Administration Record (MAR) on 8/15/24 for the morning and afternoon dose. R1 was sent out to the hospital and returned to the facility with a decreased dose in her psychotropic medications. R1's nurses note dated 8/6/24 documents medication at lunch held, R1 lethargic not able to feed herself. (There was no documentation the physician was notified). R1's nurses note dated 8/12/24 documents, R1 very sleepy refusing to eat lunch, afternoon medication held, not able to take medication. (There was no documentation the physician was notified). R1's nurses note dated 8/14/24 documents, R1 refused to eat breakfast, took morning medications. She refused to eat lunch, lethargic, noon medications held. R1 seen by V14 (Psych NP) new orders in place. R1's nurses note dated 8/14/24 documents, R1 refused to eat dinner, Seroquel 100 mg held this evening due to lethargy. R1's Psych NP note dated 8/14/24 documents asked to R1 for increased sleepiness for the past two days. R1 encountered in the wheelchair moaning to tactile, did not open eyes. Discussed with NOD (nurse on duty) will hold clonazepam and Seroquel when drowsy/sleepy. R1's nurses note dated 8/15/24 by V4 documents R1's daughter visibly upset about mother's mental status. R1 sitting up in wheelchair increased lethargy, right sided mouth drooling and upper extremity weakness. R1 drowsy and unable to respond to verbal stimuli. R1's daughter expressed this is not her normal behavior. R1 observed increased sedation post am scheduled medications. R1 sent out to the local hospital. R1's V16 (Nurse Practitioner) note dated 8/15/24 documents R1 seen for lethargy, R1 agitated this morning, poor appetite, more sedated now. Somnolent (excessive drowsiness), opens eyes briefly, nonverbal, acute somnolent worsening; ER for evaluation, R1's Medication Administration Record dated August 2024 shows orders for clonazepam 0.5 mg give one tablet three times a day for anxiety; Seroquel 100 mg one tablet three times a day for unspecified mood affective disorder (the orders do not show to hold if sleepy/drowsy on 8/15/24 for the am and pm dose). R1's MAR shows on 8/15/24; Seroquel 100 mg and Clonazepam 0.5 mg was documented given for the am and afternoon dose. R1's MAR shows orders for antipsychotic medication monitor for dry mouth, constipation, blurred vision, disorientation, confusion, lethargy, drooling, difficulty urinating .start date of 8/17/24 (after hospitalization ). The facility's Psychotropic Medication Policy states, Psychotropic medications include any drug that affects brain activities associated with mental processes and behavior physicians and physician extenders (Physician Extender and Nurse Practitioner) will use psychotropic medications appropriately, working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring .monitoring psychotropic drug use daily, noting any adverse effects such as increased somnolence or functional decline .

Based on interview and record review the facility failed to ensure two residents (R2 & R3) were free from non-consensual sexual contact/touching by R1 who has a history of touching females (residents and staff) inappropriately. This applies to 3 of 3 residents (R1, R2, & R3) reviewed for sexual abuse in the sample of 7. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on January 20, 2021 when R1 grabbed R3's breasts. The Immediate Jeopardy was identified on August 23, 2021. V1 Administrator was notified of the immediate Jeopardy on August 25, 2021. The surveyor confirmed by observation, interview, and record review the Immediate Jeopardy was removed on August 25, 2021; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The facility's final investigation for an allegation of abuse that occurred on August 11, 2021 shows, Incident: On August 11, 2021 at approximately 5:30 PM, R3 was observed after dinner service propelling herself using her legs while seated in the wheelchair toward the dining room door. As V4 Registered Nurse (RN) passed the dining room, she observed a male resident R1 seated, in his wheelchair by the entrance of the dining room door. As resident R3 exited the dining room, the nurse observed resident R1 block resident R3 from leaving the doorway. V4 RN witnessed R1 pull the wheelchair of R3 towards him, reach out with an open hand, grab the left breast of R3 and squeeze. The nurse immediately separated the two residents and brought R3 to her room. Prior to V4 RN who witnessed the incident being able to inform the resident's primary nurse, R1 was observed by V10 Certified Nursing Assistant (CNA) reaching out and grabbing the breasts of another female resident, R2. V10 CNA immediately separated the two residents and brought R2 to the nurse's station. At that time, the primary nurse (V6) was present and brought R1 to his room . Investigation: Interview with V10 CNA: per V10 CNA, she was in the dining room assisting another resident when she heard resident R2 scream, leave me alone you pig! When she turned around, she saw R1 grabbing the breasts of R2. She immediately separated both residents and brought resident R2 to the nurse's station . Conclusion: After extensive interviews were conducted, it was determined that resident R1 had intentionally reached out to grab the breasts of resident R3 and resident R2. Resident R1 was seen waiting at the dining room door and as resident R3 exited, resident R1 pulled R3's wheelchair closer and reached out to grab her left breast. When staff removed R3 from the area, resident R2 then exited the dining room quickly after, allowing R1 to reach out and grab R2's breasts prior to staff being able to intervene. R1, R2, & R3's electronic medical records show all three residents have a dementia diagnosis. On August 23, 2021 at 10:59 AM, R3 stated, she remembered R1 grabbing her breasts and said well they had all of us walk by him, as we walked by, he put both hands on my breasts. Pretended they needed uplifting. On August 23, 2021 at 1:06 PM, V4 RN stated, she was not R1's primary nurse on August 11, 2021 but was working the other hallway. She stopped by the dining room while passing her evening medications to see if any of her residents were in the dining room. At that time, she saw, R3 going past R1 on her way out of the dining room. R1 grabbed R3's wheelchair and pulled her back to him and grabbed her breast. R3 screamed. V4 took R3 out of the dining room to V5 RN to let her know what happened. V4 stated, she has heard R1 touches staff before. On August 23, 2021 at 1:21 PM, V5 RN stated, she was R1's primary nurse on August 11, 2021. It was dinner time and R1 was sitting by the door of the dining room at this table. One of the CNAs (V10) came to get me and said that R1 just grabbed R2's breasts. 5 minutes later he did it again to R3. She stated, she took R1 out of the dining room after he grabbed the second resident (R3). V5 just became a nurse a month ago, prior to that she was working at the facility as a CNA. She is familiar with R1 and stated, that is what he does and has done it before (grab people inappropriately), usually to staff. Not unusual for him to touch staff . I would say it has progressively gotten worse, would say in the last year, a lot more grabby. On August 23, 2021 at 2:35 PM, V3 Assistant Director of Nursing (ADON) stated, she was notified by the nurse on that hallway (V5) that R1 had grabbed 2 female residents' breasts. He has done this before in January 2021 to R3. (Second time he has grabbed R3's breasts.) He can get a little touchy with staff when they are close to him. If staff don't know him and are not comfortable we tell them to care for him with 2 people. The second person is there to help watch his hands. She also stated that she had a talk with staff that they should have taken R1 out of the dining room after he grabbed R2 the first time. R3 being touched could have been avoided. The facility's final investigation for an allegation of abuse that occurred on January 20, 2021 shows, Incident: On January 20, 2021 at approximately 3:45 PM, the off- going nurse heard R3 crying in the common area of the unit. The off-going nurse arrived in the common area and noted the resident sitting in her wheelchair next to a male resident, R1. This resident was also seated in a wheelchair next to R3. The off-going nurse then assisted R3 to the dining room to prepare for dinner and informed the current nurse of R1's behavior. The current nurse went to the dining room where R3 was sitting in her wheelchair at a table. Nurse notes R3 was not actively crying anymore but still visibly upset. When the nurse asked R3 if something was wrong the resident stated, I want to talk to my daughter. When asked further if there was anything wrong, R3 reported that R1 grabbed my breast. Conclusion: Based on multiple and extensive interviews, conducted, and statements obtained from other residents, it has been determined that the allegation of abuse is unsubstantiated . The nurse's notes for R1 dated December 27, 2020 at 12:56 PM shows, Resident grab and touch staff during ADL's (Activities of daily living). He touched writers' breast during medication administration. I explained to resident that's inappropriate to touch anyone. Resident stated, I know but it's fun for me. The nurse's notes for R1 dated December 27, 2020 at 8:21 PM shows, Resident behavior was inappropriate this shift. During assisting with ADL's, he was grabbing and touching staff in private area like breast, butt. During accucheck (check blood sugar) touched writer in the breast. Explained to resident that this is inappropriate to touch anyone without his/her permission. He was told that CNAs are afraid to take care of him because of this behavior. Resident admits that he feels anxious most of the time and he has a hard time to control what he is doing . The nurse's notes for R1 dated January 2, 2021 shows, Resident was found trying to grope a female resident's breasts from behind in his wheelchair. The female resident screamed and said, What are you doing? The female resident was upset and tried to get back to the resident . Another staff instructed the resident that it is not an appropriate behavior. However, resident kept trying touching other female resident and staff's body without consent . The nurse's notes for R1 dated January 3, 2021 shows, Resident alert with some confusion. Was attempting to grab CNA breast during care but promptly instructed not to do it then resident just laugh. The nurse's notes for R1 dated January 20, 2021 shows, Resident is alert and confused, resident grabbed other female residents' breast (R3), victim female resident was crying and wants to talk to the family up on asked resident told the staff that other male resident (R1) grabbed her breasts . The nurse's notes for R1 dated January 30, 2021 shows, noted per restorative aide, that during peri care in the bathroom, resident was rubbing his front with his pad and was told this was inappropriate and resident continued on until he was redirected to sit on the chair after care was done. R1's social service assessment dated [DATE] shows, G. Behavior: 3. Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior of this type occurred 4 to 6 days; 4. Is resident socially inappropriate? Yes; 6. Behavior Noted: R1 had a few recorded instances of grabbing and sexual inappropriateness. R1's clinical neuropsychology report dated March 11, 2021 shows, History of current symptoms: .Per staff, R1 is alert, pleasant, and cooperative; however, he shows behavioral disturbances consisting of sexually inappropriate behaviors towards female staff. This includes making inappropriate sexual comments toward female staff and grabbing female staff inappropriately. When confronted about his behaviors, R1 expresses that it's there and that the female staff are touching him when they have to change him. Staff have discussed with him that such behaviors are inappropriate; however, his behaviors recently have increased . The nurse's notes for R1 dated June 14, 2021 at 1:38 PM shows, Writer was notified by CNA that resident was touching her inappropriately, while she was helping resident with feeding . The nurse's notes for R1 dated June 14, 2021 at 4:21 PM shows, Writer spoke with resident after it was reported to writer that resident inappropriately touched a female staff member's breast and buttock. Resident at first denied touching staff and claimed he did not do it. Writer then expressed that the staff member reported it was today in the dining room and he then expressed that he remembered touching the staff member inappropriately. When writer asked resident, what made him touch the staff member, he expressed I don't know and that he will not do it again . R1's social service assessment dated [DATE] shows, G. Behavior: 3. Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior of this type occurred 1 to 3 days; 4. Is resident socially inappropriate? Yes; 6. Behavior Noted: R1 had a few recorded instances of grabbing and sexual inappropriateness. The nurse's notes for R1 dated July 8, 2021 shows, During insulin administration this resident grabbed this nurse's breast. Resident's hand removed, was asked by this nurse of what he is doing: Resident's response I am grabbing your breast when asked why- resident states because it feels good . The nurse's notes for R1 dated July 13, 2021 shows, During lunch time resident grabbed restorative CNA breast. Resident hand was removed by CNA. Writer asked resident why is he grabbing CNA resident stated because was there. The nurse's notes for R1 dated July 15, 2021 shows, Resident has one incident of sexually acting out . The nurse's notes for R1 dated August 11, 2021 shows, Received a call from residents RN reporting an incident with R1 and two female residents. R1 was waiting at the dining room door after dinner. When two female residents exited the dining room, R1 touched the female resident's breasts . On August 23, 2021 at 11:07 AM, V8 RN stated, R1 has grabbed her breast before. She has also received in report several times that he grabs on to females. I asked him why and he says, it feels good. On August 23, 2021 at 11:12 AM, V9 CNA stated, R1 grabs them when they are dressing him. Most of the time he goes for the boobs. If we pass by him, even though we tell to keep his hands to his self, he's gonna do it. (Grab you inappropriately). R1's minimum data set (MDS) dated [DATE] shows, he is cognitively intact. R1's care plan date initiated August 10, 2020 shows, Focus: R1 has a behavior problem of grabbing and touching staff inappropriately . The facility's abuse detection and prevention policy dated February 25, 2013 shows, Policy: It is policy of the facility that residents are to be free from verbal, sexual, physical, and emotional/mental abuse; neglect; self-abuse/self-neglect; medical neglect; misappropriation of resident property; corporal punishment; and involuntary seclusion at all times. Definitions: Sexual abuse is defined as sexual contact with a person without their consent or with any person incapable of giving consent. It includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. The Immediate Jeopardy that began on January 20, 2021 was removed on August 25, 2021 when the facility took the following actions to remove the immediacy. 1. All CNA and nursing staff have and will receive education regarding abuse identification, prevention, and intervention. a. Education has been provided by the Director of Nursing and nursing managers to nursing and CNA staff regarding abuse identification and prevention including sexual abuse beginning on 8/23/21 and will continue until all nursing and CNA staff have received the education prior to the start of their next scheduled shift. b. Education has been provided by the Director of Nursing and nursing managers to nursing and CNA staff regarding abuse interventions and how to safely manage escalating behaviors beginning on 8/25/21 and will continue until all nursing and CNA staff have received the education prior to the start of their next scheduled shift. Education will be completed by 9/1/21. 2. R1 is currently out of the facility at the inpatient psych hospital for medicinal changes and behavioral intervention. If R1 is stable and appropriate to return, the care plan will be amended immediately upon admission to ensure R1 does not have an opportunity to harm any vulnerable residents. Interventions may include: 14-day quarantine in room, related to COVID protocol, resident to be monitored while out in common area, resident requires assistance with meals. Resident will have meals in dining room away from female residents. Provide cueing and direction for hand placement during meals. Resident to be brought back to room immediately after meal, provide frequent monitoring of resident when he is in his room, resident will participate in activities of choice maintain distance of 6 feet or more from female residents, resident utilizes the wheelchair as primary mode of transportation. He requires extensive assistance with locomotion. Monitor for resident's ability to self-propel while in wheelchair and maintain visual monitoring. Immediately remove resident when he propels himself within 6 feet of any female resident, Assistance with ADL's will be provided by male associates when possible. If female associates provide personal care, said care will be provided by two staff, Provide resident with reminders and cuing for hand placement during are, any attempts by resident of inappropriate sexual behavior will be immediately reported to nurse/supervisor for immediate and appropriate action including involuntary discharge to Behavioral Health and/or involuntary discharge from the facility, administer medications as ordered, monitor and document effectiveness or side effects of medication, resident to be followed by psychiatry for behavioral management, resident to be followed by neurology for management of symptoms of tardive dyskinesia related to [CONDITION(S)]. 3. All CNA and nursing staff will be educated on sexual abuse and facility policy and procedure for reporting potential abuse. a. Education has been provided by the Director of Nursing and nursing managers to nursing and CNA staff regarding facility abuse policies and procedures including reporting protocols on 8/23/21 and will continue until all nursing and CNA staff have received the education prior to the start of their next scheduled shift. Education will be completed by 9/1/21. 4. Facility will complete random audits for those identified residents with behaviors to determine if the behaviors are being managed appropriately in accordance with their care plans, and to determine if additional intervention is needed. Random audits will be conducted at least 10 times weekly for a period of 8 weeks. Results of the audits will be reported to the QAPI committee. 5. Facility Administrator and Director of Nursing reviewed the facility policies for; Behavioral Assessment, Intervention, and Monitoring; and Unmanageable Residents Behavior on 8/25/21. 6. Residents R2 and R3 will be monitored for the next few weeks to determine if they need any additional emotional or psychosocial support. Any additional interventions will be incorporated into their individual care plans.

Based on observation, interview, and record review the facility failed to follow recommended guidelines from Centers for Disease Control (CDC) by not wearing N95 masks and Personal Protective Equipment (PPE) for persons under investigation (PUI) to rule out COVID-19 who are on transmission based precautions (contact/droplet precautions). The facility failed to initiate isolation and maintain transmission-based precautions for PUI residents. These failures have the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This applies to all 141 residents residing in the facility. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on June 14, 2021 when the facility staff did not wear N95 masks when entering residents' rooms who were on contact/droplet isolation. The Immediate Jeopardy was identified on June 16, 2021. V1 Administrator was informed of the Immediate Jeopardy on June 16, 2021 at 11:22 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on June 16, 2021; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The Resident Census and Conditions Report (Form 672) dated June 14, 2021 shows that there are 141 residents residing in the facility. The facility provided PUI list dated June 14, 2021, shows that R5, R13, R50, and R145 are on the PUI list and are on contact/droplet isolation. R20 is not listed on the PUI list. On June 14, 2021 at 1:35 PM, V2 said at this time 6 out of 141 residents are not vaccinated and 28 out of 135 staff are not vaccinated. On June 14, 2021 at 11:00 AM, V2 Director of Nursing (DON) said in PUI rooms staff are required to wear a surgical mask, goggles or a facemask, gown, and gloves. Residents in PUI rooms are on contact/droplet isolation due to a high risk of exposure, are displaying signs and symptoms of COVID-19, and or are not vaccinated or have no proof of vaccination for COVID-19. V2 said these residents on PUI are not allowed out of their rooms. On June 14, 2021 at 11:53 AM, V2 stated we are on a contingency basis since we only have a certain amount of N95 masks. We are only using surgical masks for the PUI rooms instead of the N95 masks. For droplet precaution, if not in contingency basis, we follow the CDC and IDPH guidelines and use the N95 mask, goggles or face shield, gown, and gloves. As long as the residents are not positive for COVID-19 we use the surgical mask. We have had trouble getting N95 masks from suppliers. We have 4 varieties of N95 masks, and we have not enough of one of the 4 varieties. On 06/14/21 at 12:33 PM, V2 said R13 and R5 are running temperatures so our procedure is to put them in PUI isolation. R50 goes out for [CONDITION(S)] so is a high-risk exposure and is on PUI. R145 has been running fevers so we put him on PUI isolation today. Are purchasing department handles ordering supplies. V8 (Purchasing) is the gate keeper for PPE, she places orders every week. 1. On June 14, 2021 at 10:21 AM, R50 was outside of his room getting mail from staff without wearing a mask, and then wheeled himself back into his room. The sign on R50's door said droplet contact precautions quarantine and R50's door was open. On 06/14/21 at 02:10 PM, V6 Certified Nursing Assistant (CNA) wearing a surgical mask only, walked into R50's room to deliver R50's lunch tray and did not put any Personal Protective Equipment (PPE) on. R50's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On June 14, 2021 at 11:57 AM, V9 CNA said to go into a contact/droplet isolation room (PUI room), you have to wear a surgical mask, face shield, gloves and a gown before entering the room. On June 14, 2021 at 12:01 PM, V10 CNA went into R145's room wearing gloves, gown, face shield, and a surgical mask. When V10 opened R145's door, V11 Speech Therapist was standing at R145's bedside wearing only a surgical mask. 3. On June 14, 2021 at 11:04 AM, R13's isolation sign was located outside of his room and said Quarantine droplet/contact precautions. V4 Registered Nurse (RN) said R13 is on isolation for [CONDITION(S)]. On June 14, 2021 at 12:56 PM, V5 (CNA) entered R13's room only wearing a surgical mask. V5 did not don PPE before entering R13's room. R13's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note dated June 5, 2021 documents R13 has a temperature of 100.4 F (Fahrenheit). 4. On June 14, 2021 at 12:15 PM, R20 was in the dining room with several other residents. R20 did not have any mask on. At 1:01 PM, V5 CNA wheeled R20 into her room. R20 did not have an isolation sign outside of her room. R20 is residing in a room with R61. On June 15, 2021 at 8:58 AM, R20 is in her room with R61, both residents were observed eating in their rooms. R20 did not have an isolation sign/cart located outside of her room. On June 14, 2021 at 2:32 PM, V4 (RN) said R20 is on an antibiotic for a cough and fever. V4 said R20's isolation was discontinued. V4 said if a resident has a fever they are placed on droplet/contact precautions for 14 days. The nurse's note dated June 8, 2021 documents R20 has a temperature of 99.8 F. R20's vital report shows a temperature of 99.0 F. R20's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The P.O.S shows no orders to discontinue her isolation. 5. On June 14, 2021 at 11:54 AM, R5's isolation sign located outside of his room said Quarantine droplet/contact precautions. R5 was observed self-propelling himself down the hall with no mask on and wheeled himself back into his room. At 11:58 AM, R5 wheels himself down the hall and back to his room with no mask on. At 12:08 PM, R5 wheeled himself outside of his room halfway down the hall. V4 (RN) approached R5 wearing only a surgical mask and administered his noon medications in the hall. V7 (CNA) wheeled R5 into his room only wearing a surgical mask and did not put on PPE. On June 14, 2021 at 10:44 AM, V4 said R13, R5, R54, and R195 are on droplet/contact precautions. V4 said staff should wear gown, gloves, face shield/goggles and a mask. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/14/21 at 02:19 PM, V8 along with V2 showed this surveyor the facility's PPE supply room. The supply room contained numerous boxes of N95 masks and other PPE. V8 stated we have 9000 N95 masks right now. One of the 4 varieties we use we were down to about 60 total but we have just started receiving them. I calculated our burn rate to be about 4800 so we are about 20% over that. I do not have any masks on order right now because I am comfortable with the supply we have. I do have a back-up company to order N95 masks from. I have not received any correspondence from my suppliers about N95 masks not being available. The facility's COVID-19 Interim Infection Control Prevention and Control for residents with Suspected or Confirmed COVID-19 dated 3/21/21 shows associates who enter the room of a resident with known or suspected COVID-19 should use an N95 or higher respirator or facemask, gown, gloves, and eye protection .resident with known or suspected COVID-19 will be placed in a single-occupancy room with the door closed . Transmission based precautions will be followed at all times when entering the residents' room. The CDC's preparing for COVID-19 in nursing homes last updated November 20, 2020 shows, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown: Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (healthcare professional) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents . The Immediate Jeopardy that began on June14, 2021 was removed on June 16, 2021 when the facility took the following actions to remove the immediacy. -All staff interacting with residents on droplet contact precaution will wear the appropriate PPE in accordance with CDC recommendations including the use of N95 mask for any PUI residents -Staff use of N95 masked for all residents on droplet contact precautions was implemented on 6/15/21. -Policy revision to reflect N95 usage for residents on droplet contact precautions has been completed 6/16/21. -Transmission based precautions care plan updates for all residents on droplet contact precautions were completed on 6/16/21. -Education has been provided by the Director of Nursing and nursing managers to nursing and CNA staff regarding PPE and PPE utilization for residents on droplet contact precautions beginning on 6/15/21 and will continue until all nursing and CNA staff have received the education prior to the start of their next scheduled shift. Education will be completed by 6/25/21. -The Director of Nursing or designee will make daily observations of proper PPE usage for residents on droplet contact precautions three times daily for a period of 4 weeks. -All residents with signs or symptoms of COVID like illness (CLI) have been place on droplet contact precautions and any residents with new CLI will be placed on droplet contact precautions immediately. -Residents with CLI have been placed on droplet contact precautions, in accordance with current IDPH regulation. -All residents on droplet contact precautions will remain in their rooms with the door closed. -The practice of closing the door and ensuring the resident remains in their room while on droplet contact precautions was implemented on 6/15/21. -Education by the Director of Nursing and nursing managers had been provided to nursing and CNA staff regarding residents on droplet contact precautions remaining in their rooms with the door closed beginning on 6/15/21 and will continue until all nursing and CNA staff have received the education prior to the start of their next scheduled shift. Education will be completed by 6/25/21. -The Director of Nursing or designee will make daily observations of proper PPE usage for residents on droplet contact precautions three times daily for a period of 4 weeks.

Based on interview and record review the facility failed to immediately perform COVID-19 testing on residents who showed signs and symptoms (fever/cough) of COVID-19. These failures have the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This applies to all 141 residents residing in the facility. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on June 3, 2021 when a resident showed signs/symptoms of COVID-19 and the facility failed to perform COVID-19 testing. The Immediate Jeopardy was identified on June 16, 2021. V1 Administrator was informed of the Immediate Jeopardy on June 16, 2021 at 11:22 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on June 16, 2021; however noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The facility's Resident Census and Conditions of Residents form dated June 14, 2021 shows 141 residents residing in the facility. The facility's undated map shows R13, R20 and R54 all reside on the same wing (Forest Wing). 1. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note dated 6/3/21, documents R54 had a fever of 100.6 degrees and the physician was notified and R54 was placed on droplet isolation. The nurse's note dated 6/6/21 documents R54 is complaining of difficulty breathing and a temperature of 99.9 degrees. R54's Vitals report shows: 6/3/21- 100.6 degrees (temperature) 6/5/21- 99.9 degrees 6/6/21- 99.9 degrees at 4:30 PM, 9:48 PM R54's Laboratory COVID-19 test was last performed on 6/2/21. On June 14, 2021 at 3:15 PM, V2 (DON) said if a resident shows signs/symptoms of COVID-19 we would do a rapid COVID test and PCR (Polymerase chain reaction) immediately to rule out COVID-19. 2. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note dated 6/5/21 documents R13 had a temperature of 100.6 degrees. R13's Vitals report for June 2021 shows: 6/4/21- 100.0 degrees (temperature) 6/5/21- 100.4 degrees R13's Laboratory COVID-19 test was last performed on 5/26/21. (There was no evidence of testing after this date). 3. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician Note dated 6/9/21, documents R20 had a fever last evening with a cough. R20's vitals report for June 2021 shows: 6/8/21- 99.2 degrees 6/13/21- 99.0 degrees R20's Laboratory COVID-19 test was last performed on June 4, 2021. (There was no evidence of testing after this date). On June 15, 2021 at 3:08 PM, V17 (Medical Director) said if a resident is having signs and symptoms of COVID-19 including cough and fever they should be tested for COVID-19 within 1-2 days and placed on isolation. On June 15, 2021 at 3:00 PM, V2 Director of Nursing said currently based on the county positivity rate we are testing staff and residents monthly, our next scheduled testing is June 28, 2021. On June 15, 2021 at 1:06 PM, V3 (Infection Control Preventionist) said if a resident has a change in their vitals or any change that is not their norm including fever they are placed on quarantine. We look at the whole picture before we test them for COVID-19 and we would not test the residents immediately for COVID-19 first. V3 said the only way to rule out COVID-19 is to perform a COVID-19 test. V3 said we did test one resident who had an elevated temperature after a pattern of three residents had similar symptoms. The facility's COVID-19 testing Plan dated March 25, 2021 states, Residents in congregate settings such as in Nursing Homes are at a high risk for infection, serious infection, serious illness, and death from COVID-19. [CONDITION(S)] testing for [CONDITION(S)]-CoV-2, the virus that causes COVID-19, in respiratory specimens can detect current infections among residents and associates. [CONDITION(S)] testing for COVID-19 aims to aid in: the prevention of the virus from entering the community, the detection of COVID-19 cases in the community quickly .Asymptomatic infection with [CONDITION(S)]-CoV-2 has been reported. Most residents with confirmed COVID-19 develop fever and/or symptoms of acute respiratory illness (e.g., cough, difficulty, and breathing) .Detection .The community will continue to actively screen all residents for COVID-Like illness (CLI) .Any resident who exhibits symptoms consistent with COVID-19 with a high degree of suspicion will be tested .consider testing of any resident or associate who subsequently develops fever or symptoms consistent with COVID-19. The Centers for Disease Control (CDC) Testing Guidelines for Nursing Homes updated on January 7, 2021 states, Nursing home residents are at high risk for infection, serious illness, and death from COVID-19. Testing for [CONDITION(S)]-CoV-2, the virus that causes COVID-19, in respiratory specimens detects current infections (referred to here as [CONDITION(S)] testing) among residents in nursing homes. [CONDITION(S)] testing of residents in nursing homes, with authorized nucleic acid amplification tests or [MEDICATION(S)] detection assays, is an important addition to other infection prevention and control (IPC) recommendations aimed at preventing [CONDITION(S)]-CoV-2 from entering nursing homes, detecting cases quickly, and stopping transmission. This guideline is based on currently available information about COVID-19 and will be refined and updated as more information becomes available. Testing conducted at nursing homes should be implemented in addition to recommended IPC measures. Facilities should have a plan for testing residents for [CONDITION(S)]-CoV-2. Additional information about the components of the testing plan are available in the CDC guidance titled Preparing for COVID-19 in Nursing Homes. The CDC's Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination dated April 27, 2021 shows [CONDITION(S)]-CoV-2 Testing Anyone with symptoms of COVID-19, regardless of vaccination status, should receive a [CONDITION(S)] test immediately. The Immediate Jeopardy that began on June 3, 2021 was removed on June 16, 2021 when the facility took the following actions to remove the immediacy. -The facility testing plan was updated on 6/26/21 to ensure that any resident with signs/symptoms of COVID like illness (CLI) are tested via POC (point of care) testing and PCR (polymerase chain reaction) testing immediately. -Education by the Director of Nursing and nursing managers has been provided to nursing and CNA staff regarding the use of POC and PCR testing beginning on 6/15/21 and will continue until all staff have received the education prior to the start of their next scheduled shift. Education will be completed by 6/25/21. -The Director of Nursing and Administrator have completed a comprehensive review of the current COVID-19 regulations provided by the CDC, LHD, and IDPH. Given the continuing changed in guidance, both the DON and Administrator will continue to remain informed of changes through the weekly IDPH update calls and SIREN alerts. Friendship Village maintains that its COVID policies are current and reflective of the current IDPH guidance. -Nursing and CAN staff training by the Director of Nursing and nursing managers regarding the COVID Testing Plan for residents and associates will be provided to agency staff upon arrival for their scheduled shift beginning on 6/16/21. Education will be provided to facility nursing and CNA staff by the Director of Nursing and nursing managers regarding the testing plan starting 6/16/21 and will continue until all staff have received the education prior to the start of their next scheduled shift. Education will be completed by 6/25/21.

Based on observation, interview, and record review the facility failed to prevent an at risk resident from developing an unstageable pressure wound, have pressure wound dressings in place, have pressure interventions in place, and failed to assess and measure pressure wounds for 4 of 11 residents (R44, R55, R65, R97) reviewed for pressure wounds in a sample of 28. These failures contributed to a resident (R55) developing three unstageable pressure wounds that have declined and now requires intravenous antibiotics. The findings include: 1. On 6/14/21 at 11:34 AM, R55 was lying in bed. R55 had a regular mattress on her bed. R55's heels were directly on the bed. On 6/16/21 at 11:33 AM, R55 was sitting up in her wheelchair. R55 requested to go to the bathroom. R55's heel protectors were removed and R55 was transferred to the toilet using the sit to stand lift. R55's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R55's POS shows an order dated 4/9/21 for, weekly skin/wound assessment, document in progress notes every day shift every Thu (Thursday). Include measurement, description of wound, signs of infection if applicable. R55's Skin Integrity Care Plan shows, 1/23/21-R (right) heel DTI, 2/4/21 R distal great toe DTI, 3/16/21 R bunion DTI Apply heel protectors when in bed .Heel protectors to both feet during SST (Sit to Stand) transfer to avoid feet/toes to touch SST footboard .wound tx (treatment) as ordered . R55's Electronic Medical Record (EMR) shows a skin note dated 1/6/21 that shows skin intact with no open areas and blanchable redness on both feet. R55's progress note dated 1/26/21 shows, Requested by staff to re-assess skin breakdown to resident's R (right) heel. Noted an intact, blood filled DTI (Deep Tissue Injury) to her right heel measuring 1 cm x 1 cm, with intact serum filled blister on DTI edges During assessment it was noted that resident was putting more weight to her R heel towards the bed than her L (left) heel. Recommended to apply [MEDICATION(S)] to R heel DTI and continue with heel protectors. No additional measurements were documented until 2/4/21. (29 days later). R55's skin notes dated 2/4/21 shows, Requested by staff to assess black spot on resident's R great toe. Noted an intact, dark bluish DTI in her distal great toe measuring 0.5 cm (centimeters) x 0.5 cm .Also assessed DTI/intact blister in her R heel which is now measures approx (approximately) 3 cm x 3 cm and is partially filled with serum with bluish edges .Resident is being transferred with a SST lift. It appears that DTI on her R distal great toe is caused by her toes hitting the foot board of the SST lift during transfers Will instruct and discuss with staff to have resident wear her heel protectors during transfers to avoid her foot/toes to touch the foot board . No additional wound measurement was documented until 4/15/21 (70 days later). R55's 4/16/21 skin notes show, Reassessed residents R heel, R bunion and R distal great toe eschars, and BLE (bilateral lower extremities) together with NP (Nurse Practitioner). R heel eschar is black, dry, intact and stable measuring 1.2 cm x 0.8 cm R bunion eschar measures 1 cm x 1.5 cm and is black, intact, with scant serous drainage and mildly macerated woundedges with minimal [CONDITION(S)] on periwound R distal great toe eschar is dry, intact and stable, and measures 1 cm x 1.5 cm. No additional measurement was documented until 6/16/21 (61 days later). R55's skin notes dated 6/16/21 shows, Reassessed resident's R heel, R bunion, and R distal toe eschars/ulcers. R heel black, dry eschar now measures 1 cm x 1 cm with no depth. R bunion eschar now measures 2.6 cm x 3 cm x 0.2 cm (last measurement was 1 cm x 1.5 cm) with loose unstable eschar and slough on wound bed, and minimal serous drainage. R lateral foot eschar 1.5 cm x 1.5 cm no measurable depth with thin slough on wound edges. Her R foot is ruddy red. R55's POS shows that she was started on [MEDICATION(S)] (antibiotic) on 6/11/21 due to right foot [CONDITION(S)]. On 6/16/21 at 11:25 AM, V22 (Wound Care Nurse) said that R55 has DTI pressure ulcers on her right foot and are currently being treated with [MEDICATION(S)] and off-loading her feet. V22 said that her foot is now red and her wounds are getting worse. V22 said that R55 is compliant with wearing her heel protectors. At 11:33 AM, V22 said that R55 used to have an air mattress but he does not know why she does not have one now. At 12:30 PM, V22 said that R55 does have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V22 said that he does not know why they were not done weekly as ordered. V22 said that R55's foot now has redness and she is on antibiotics. On 6/16/21 at 1:03 PM, V28 (Nurse Practitioner) said that R55 has redness around the right hallux DTI and on the top of her foot and is now on antibiotics. V28 said that if a wound is left unchecked, it could get infected or worsen. V28 said that if pressure relieving interventions are not in place, the wound could get worse. The facility's Skin Management-Pressure Ulcer (Injury) Prevention and Management Policy revised on 11/24/17 shows, Individualized interventions will be implemented for at risk residents based on risk assessment findings .For an actual pressure injury. Physician will be notified and treatment initiated as ordered .If progress is not noted in 2 weeks or deterioration is present, Physician is notified for treatment order review. The Facility's Pressure Ulcer Treatment Procedure revised on 10/26/20 shows, Assess the wound and surrounding skin for [CONDITION(S)], redness, drainage, tissue healing progress and wound stage .The following information should be recorded in the resident's medical record, treatment sheet or designated wound form .Wound appearance, including wound bed, edges, presence of drainage All assessment data (i.e. wound bed color, size, drainage, etc) obtained when inspecting the wound. 2. R44's Admission Record printed June 16, 2021 showed R44 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R44's Facility assessment dated [DATE] showed R44 to be cognitively impaired, at risk for pressure injuries, and needing extensive to total dependence of staff for activities of daily living (ADLs) which includes bed mobility and transfers. R44's Pressure Risk Assessment (Braden Scale) dated April 27, 2021 showed R44 to be at risk for developing pressure wounds. On June 14, 2021 at 12:15 PM, R44 stated he had developed a wound on his left heal several weeks ago in the facility. R44 stated he cannot move his legs since his back surgery and does not have good sensation due to [CONDITION(S)]. R44's Skin/Wound Note dated May 25, 2021 showed V22 (Wound Nurse) was contacted to look at a new wound on R44's left heel. V22 noted a deep tissue injury measuring 3 centimeters (CM) by 5 cm on R44's left heel. R44's Wound Physician Notes dated May 27, 2021 showed R44 having a new unstageable pressure wound to the left heel measuring 3.7 cm X 5.5 cm X 0 cm with recommendations of off-load wound .sponge boot. R44's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On June 15, 2021 at 12:00 PM, R44 was in his wheelchair in front of his room. R44 did not have a padded boot on his left foot. R44's heel was on the footrest of the wheelchair. R44 stated he was on his way to lunch and pointed down the hall toward the nurse's station. On June 16, 2021 at 9:15 AM, V22 stated R44 developed a new pressure wound to his left heel. After R44's surgery to his back he had to lay flat. V22 stated R44's inability to move his legs and poor sensation are contributing factors in his development of his heel wound. R44 had a habit of putting his heel on the edge of his wheelchair footrest. V22 stated R44 is now to wear his left padded boot at all times to prevent further injury to the wound. 3. R65's Admission Record shows she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R65's Scale for Predicting Pressure Ulcer Risk dated 5/12/21 shows, R65 is at high risk for developing pressure injuries. On 6/14/21 at 12:46 PM, V6 CNA (Certified Nursing Assistant) was providing incontinence care to R65. Two skin areas were identified during incontinence care. V6 said incontinence care was last done before breakfast. R65 had stool and dark urine in her incontinence brief. There was a quarter size reddened opened area to R65's right buttock and a pencil eraser sized area to R65's sacrum that was filled with slough. V22 Wound Care Nurse said the wound to R65's right buttock was healed and now it is a stage 3 and R65's sacrum wound is unstageable. V22 asked V25 RN (Registered Nurse) to clean the wounds with normal saline and put cream on them. V25 then wiped R65's wounds with a peri care wet wipe (not normal saline) and placed cream on them. R65's Skin/Wound noted dated 6/14/21, done by V22 shows, requested by staff to assess resident's pressure injuries on the right buttock and sacrum that have previously closed and resolved. Noted reopened stage 3 pressure injury in the right buttocks now measuring 2 cm (Centimeters) X 1.5 cm with no measurable depth and has beefy red granulating wound bed, with scant bleeding, and irregular wound edges. The sacrum stage 3 pressure injury that had previously closed and resolved has also reopened, this time with thin slough (unstageable) on wound bed, scant serous drainage, and defined and intact wound edges. Will have resident be seen again by wound doctor on next wound doctor visit. Resident is on tube feedings, incontinent of bowel and bladder, and is dependent on staff with ADLs (Activities of daily living). V25's RN (Registered Nurse) skin/wound note dated 6/14/21 shows, Resident skin assessment was made in presence of wound nurse, old wound reopen-sacrum pressure injury measures 1 cm X 0.8 cm X 0 cm. Right buttock pressure injury measures 2 cm X 1.5 cm X 0 CM. R65's Care Plan revised on 5/1/19 shows, Observe for any skin impairment and report to nurse/supervisor. Care Plan initiated 3/26/21 and revised on 6/14/21 shows, 4/1/21 right buttock unstageable, stage 2 coccyx/sacrum. 4/26/21 sacrum resolved. 4/26/21 right buttock unstageable. 6/14/21 right buttock stage 3 reopened. 6/14/21 sacrum unstageable reopened. 4. On 6/14/21 at 2:13 PM, V6 CNA perform incontinence care to R97. There was urine and stool in R97's incontinence brief. R97 had a foam dressing to her left lower buttock that was not intact. The dressing was saturated, and the wound and treatment packing was visible. V6 performed peri care, placed R97's incontinence brief on and positioned R97 in bed. V6 said incontinence care was last done to R97 at 9 or 10 AM. On 6/14/21 at 2:47 PM, V25 RN said she was not aware R97's dressing was not intact. R97's Care Plan revised on 5/10/21 shows R97 has a stage four pressure injury to her left ischium 4/15/21. Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R97's Order Summary Report shows an order to change R97's dressing daily and as needed. On 6/16/21 at 12:45 PM, V25 said if a CNA sees that a dressing is no longer intact, then the CNA should tell the nurse right away so a new dressing can be placed. The facility's Skin Management-Pressure Injury Prevention and Management Policy dated 11/24/17 shows, Individualized interventions will be implemented for at risk residents based on risk assessment finding.

Based on interview and record review the facility failed to safely transfer a resident by not using a gait belt. This failure resulted in the resident falling and sustaining a right knee fracture. This applies to 1 of 5 residents (R1) reviewed for safety in the sample of 5. The findings include: The facility's Incident report dated (MONTH) 6, (YEAR) shows on (MONTH) 1, (YEAR) while being transferred from the wheel chair back to bed, R1 fell to the floor landing on his right knee .R1 did receive a non-displaced right patella fracture as a result of his fall. On (MONTH) 11, 2019 at 8:45 AM, V5 (R1's wife) said on (MONTH) 1, (YEAR), she was in the room with R1 who wanted to go back to bed. V5 said V6 Certified Nursing Assistant (CNA) came in to help R1 back to bed from his wheelchair. V5 said she told V6 she would need to use the belt (which was in V6's pocket) to transfer R1 because he was feeling weak and tired. V6 (without using the gait belt) grabbed R1 by the elastic band of R1's shorts and tried to transfer R1. V5 said the elastic in R1's pants broke and R1 fell to ground, hitting his right knee. V5 said the doctor at the hospital told her R1 had a fractured knee and R1 was given a brace for his knee. V5 said the brace caused R1 even more pain and R1 was not able to wear it. V5 said after R1's fractured knee R1 was unable to stand up anymore. On (MONTH) 10, 2019 at 10:42 AM, V2 Director of Nursing (DON) said staff is to use gait belts at all times during transfers. V2 said V6 was given a final warning after the fall incident with R1 for not using a gait belt during the transfer and then later terminated for a repeated occurrence of not using the gait belt. The facility's Notice of Disciplinary Action dated (MONTH) 2, (YEAR) for V6 shows (MONTH) 1, (YEAR)-associate failed to follow policy and procedure to utilize a gait belt for a resident transfer which contributed to a fall. On (MONTH) 10, 2019 at 11:55 AM, V3 Nurse Unit Manager said she had reviewed R1's fall and V6 was counseled in regards to the fall for not using a gait belt during the transfer. The facility's Occurrence Report dated (MONTH) 1, (YEAR) shows V6 was the CNA on duty and V5 witnessed the fall and resident stated feel tired, weak today. R1's Progress Note dated (MONTH) 1, (YEAR) shows R1 fell orders received to send to hospital emergency room for eval and treatment. R1's Hospital Orthopedic Physician Consultation Report dated (MONTH) 2, 2019 shows Reason for Consultation- right knee pain and patella fracture after fall .patient being transferred to wheelchair at the rehab facility when he sustained a fall injuring his right knee Assessment: status [REDACTED]. R1's Minimum Data Set, dated dated dated (MONTH) 31, (YEAR) shows R1 required extensive assistance of one person for transfers and is not steady, only able to stabilize with staff assistance during surface to surface transfers. R1's Morse Fall Scale dated (MONTH) 24, (YEAR) shows R1 is at high risk for falls. The facility's Safe Resident Handling Policy dated (MONTH) (YEAR) shows Gait belt usage is mandatory for all resident assists.

Based on observation, interview and record review, the facility failed to implement individualized fall risk interventions for residents identified as a high fall risk, and failed to identify and implement new interventions to prevent further falls. This failure resulted in R1 sustaining a right hip fracture. This failure also resulted in psycho-social impact for R3, who now fears leaving his room to eat in the dining room. This applies to 3 of 3 residents (R1, R2, R3) reviewed for falls. The findings include: 1. The EMR (electronic medical record) shows R1 was admitted to the facility on [DATE] and discharged on [DATE]. R1 is no longer in the facility. Nursing documentation dated January 5, 2017 shows R1 was admitted to the local hospital with right hip fracture following a fall at the facility. R1's face sheet dated May 31, 2017 shows R1 had multiple [DIAGNOSES REDACTED]. Nursing documentation of report between the facility and the hospital showed R1 was a high fall risk. The initial nursing assessment for R1 dated January 4, 2017 showed R1 usually understood others, but had difficulty communicating some words or finishing thoughts, and R1 usually understands, but misses some part/intent of message but comprehends most conversation. R1 had short and long-term memory problems, was easily distracted and unaware of surroundings. R1's fall risk assessment dated [DATE] showed R1 was a high fall risk. RCIs (Resident Care Instructions), used to alert staff to resident's care needs, dated January 5, 2017 showed R1 required 1 person assist with ADLs (activities of daily living), transfers, and toileting. R1 was alert but confused and required a walker or wheelchair for mobility. R1's care plan dated January 5, 2017 at 7:13 AM showed: (R1) is at risk for falls due to poor safety judgement. Interventions: Use alarm to monitor attempts to rise. Footwear will fit properly and have non-skid soles. Provide (R1) with hip/knee protectors. Remind (R1) to call for assistance before moving from bed-to-chair and from chair-to-bed. Respond promptly to calls for assist to the toilet. E5's (RN-Registered Nurse) documentation on January 5, 2017 at 3:40 PM showed, PT (Physical Therapy) staff notified nursing they heard a noise and noted (R1) on the floor. This nurse saw resident laying on his right side on the floor outside of bathroom. When questioned as to pain, resident stated his right hip, right knee and lower back hurt. Confused and unable to give number on pain scale.Resident stated he was coming out of bathroom and opened the bathroom door and the machine was in the way. No machine was in the room.Resident left (facility) at 1340 (1:40 PM) with paramedics. On May 30, 2017 at 2:55 PM, E2 (DON-Director of Nursing) said, In 2014 we lowered our alarm usage. When we went to electronic medical records, the RCI became visible to all the staff. The instructions show what assistance and precautions are necessary for each resident. We print the RCI and put them on the back of the resident's bathroom door for all staff to see. We will honor family requests however. If the resident has dementia or has a fall with fracture, we may use an alarm. We find out on admit, from the Nurse Liaison if the resident has a history of falls. All new admissions are high fall risk. On May 31, 2017 at 10:54 AM, E5 said she cared for R1 on January 5, 2017, the day of the fall incident. R1 was alert, cooperative but confused. E5 said the care plan interventions of sensor alarms or hip protectors had not been put in place for R1. There were no alarms sounding when R1 fell . Staff usually follows through on interventions put on the care plan. On May 31, 2017 at 3:05 PM, Z2 (physician) said, (R1) has a history of dementia. He can be with it at times and out of it at other times. He was sent to the facility from the local hospital following hospitalization for flu and weakness. (R1) fell at the facility while attempting to use the bathroom. The fall caused (R1's) hip fracture. The facility should follow the interventions they put in place for fall prevention. (R1) was transferred to another facility following his hospitalization and is no longer under my care. On June 1, 2017 at 9:12 AM, Z4 (Therapy Manager) said, (R1) was assessed by an occupational therapist on January 4, 2017. The report showed R1 required maximum assistance by 1 person with bed to wheelchair transfers, and moderate assistance, meaning 50 to 75 percent assistance by one person with most ADLs. Facility staff has access to the evaluations in the EMR to see what assistance is required for the residents. (R1) was able to follow directions, but had poor safety awareness and was a high fall risk. 2. On May 31, 2017 at 12:05 PM, R2 was sitting in her wheelchair in her room. R2 did not have a non-skid pad on the seat of her wheelchair. Z1 (Hospice nurse) said she had transferred R2 to the wheelchair and did not put a non-skid pad under R2 because the information was not on the RCI on R2's bathroom door. Z1 confirmed this by looking at the RCI on the back of the door. The RCI did not show a non-skid pad was required for R2. R2's face sheet dated May 31, 2017 shows R2 was admitted to the facility in February 2015 with multiple [DIAGNOSES REDACTED]. R2's MDS dated [DATE] shows R2 has severe cognitive impairment, requires extensive assistance with ADLs, is incontinent of bowel and bladder and has a history of falls. R2's fall risk assessments dated January 9, February 22, March 17, and May 1, 2017 show R2 is a high fall risk. Nursing documentation dated January 28, 2017 shows R2 self-reported a fall from her recliner in her room. Nursing documentation dated February 28, 2017 shows, Observed (R2's) legs on floor outside of door of her room. Upon approaching saw resident sitting in the doorway to her room with small amount of bleeding from laceration to the left of her eyebrow approximately 2 cm. in length.Resident transported to local hospital via ambulance. R2 was admitted to the local hospital with intracranial hemorrhage. E6 (ADON-Assistant Director of Nursing) documented on March 3, 2017 in a report to IDPH (Illinois Department of Public Health), (R2) admitted to local hospital with a left-sided subdural hematoma, a chronic fracture deformity of the left radius head with a suspected new non-displaced fracture of the radius head. Nursing documentation dated March 8, 2017 shows R2 was found on the floor in her room at 3:00 AM. A follow-up meeting by the IDT on March 8, 2017 suggested a medication review should be done by the hospice staff, and a low bed was provided. Nursing documentation dated May 1, 2017 shows R2 was found on the floor in her room, near the foot part of her reclining chair at 5:50 AM by the CNA. R2 transferred herself from the bed to the reclining chair. The documentation does not mention R2's bed was in the low position. R2's RCI dated May 30, 2017 did not show the required non-skid pad on the wheelchair or the low bed. R2's care plan for high fall risk was created in March 2015. A call light in reach while in the recliner and emotional support was implemented on January 30, 2017. The low bed, medication review and staff redirection and reassurance and comfort was implemented on March 8, 2017. On May 31, 2017 at 2:00 PM, E2 said, The non-skid pad and low bed should have been added to the RCI so all staff and ancillary staff are aware of (R2's) fall precautions. The non-skid pad intervention should have been in place for the past two years. The interventions we put in place for R2 were not individualized and were actually a standard of care, such as the call light in reach and emotional support. E2 said there was no intervention in place for a non-skid pad for R2's recliner despite falls from her recliner. 3. On May 31, 2017 at 1:00 PM, R3 was sitting in his bed eating lunch. R3 said he has Parkinson's Disease and fell several weeks ago and fractured his right leg. R3 said he walked down to the dining room without any staff assistance, pulled out a chair to sit down, and fell on the floor in the dining room. R3 said, I am eating in my room now because I am very afraid to go down to the dining room to eat my meals, even in the wheelchair. That fall just haunts me. I worry I will never be the same. On June 1, 2017 at 8:30 AM, R3 was sitting in his bed eating breakfast. On June 1, 2017 at 10:34 AM, R3 was sitting in a wheelchair in the doorway of his room. R3 was yelling for help, and his call light was illuminated. No staff was present. R3 said he wanted to go back to bed and he had been waiting for about 15 minutes for someone to help him. R3 was attempting to move the wheelchair using his hands on the door frame, but was unable to move the wheelchair due the wheelchair's position up against the door frame. R3's face sheet dated May 31, 2017 shows R3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R3's MDS (Minimum Data Set) dated April 14, 2017 shows R3 is cognitively intact, requires extensive assistance with ADLs, including dressing and transfers, and has a history of falls. R3's Fall risk assessments dated April 7, 22, and May 10, 2017 show R3 is a high fall risk. The RCI dated April 18, 2017 shows R3 requires 1 person assistance with ADLs and transfers, and is a fall risk. Nursing documentation dated April 22, 2017 shows, Resident witness fall at 7:44 AM. Resident seen sitting on the floor with back resting against bed. Upon asking what happened, resident states, I was trying to put on shoe and slid off the bed. Mechanical lift used to get the resident up from the floor to bed. Nursing documentation dated April 24, 2017 shows, Fall review meeting held with IDT (interdisciplinary team). Resident fell on [DATE] at 0744 (7:44 AM).Upon further assessment, non-skid socks were on but the skid was not on the bottom of the foot Nursing documentation dated May 10, 2017 shows, At 0630 (6:30 AM), CNA (certified nursing assistant) called that resident was on the floor sitting close to bed. When checked, resident was on the floor, alert and oriented; able to move all extremities WNL (within normal limits), .wearing non-skid socks. (R3) verbalized, I just got up, this floor is so slippery, these socks they don't hold on and I just slipped. Nursing documentation dated May 17, 2017 shows, Fall review meeting held with IDT (interdisciplinary team) after (R3) fall on May 10, 2017. No serious injury.Conclusion of meeting determined slipper sock contributed to fall. New slipper socks ordered. Nursing documentation dated May 11, 2017 shows, (R3) ambulating self to the dining room with walker for breakfast. Upon coming to his table he pulled out his chair, he lost his balance or his knees gave out, he fell to the floor.X-rays taken. While laying in bed now, complained of pain in his right thigh.X-ray results to MD with right hip fracture. Ambulance called and resident transported to local hospital. R3's care plans dated April 24, 2017 showed R3 was a high fall risk due to declined functional strength and endurance. Interventions included properly fitting footwear with non-skid soles, respond promptly to calls for assist to the toilet, and proper non-skid sock positioning. R3's restorative care plan created April 13, 2017 showed, (R3) will be able to ambulate 200 feet with rolling walker to the dining room at mealtimes with limited assistance. R3's care plan created April 17, 2017 shows, Assist with ADLs (bathing, grooming, toileting, feeding, ambulating) if (R3) is unable to complete. No new care plan interventions were implemented following the fall on May 10, 2017. On May 31, 2017 at 2:00 PM, E2 said, (R3) was wearing non-skid socks backwards when he fell . He dressed himself and did not put the non-skid side facing the floor. We have since purchased different socks that have the non-skid side on the top and bottom. On June 1, 2017 at 9:12 AM, Z4 (Therapy Manager) said, The physical therapy notes dated April 14, 2017 showed (R3) required contact guard assistance for transfers, and could walk 400 feet with contact guard assistance, which means a staff member is touching the resident the whole time the activity is taking place. We have weekly meetings regarding the residents. On May 2, 2017, the meeting notes show (R3) was stand-by assist with bed mobility and transfers but still contact guard assist with ambulation. I thought (R3) was being discharged from physical therapy the day before his fall on May 11, 2017, but there is no documentation in the medical record to show (R3) had met his goals and was independent. (R3) was in the walk-to-dine program. This means that a staff member should give him some independence, but still follow along side him when he ambulates to the dining room. The facility's policy entitled, Falls - Clinical Protocol dated October 28, 2015 shows, 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall.c. After a first fall, the staff (and physicians, if possible) should watch the individual rise from a chair without using his or her arms, walk several paces, and return to sitting. If the individual has no difficulty or unsteadiness, further evaluation may not be needed. If the individual has difficulty or is unsteady in performing this test, additional evaluation should occur. Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. a. Examples of such interventions may include calcium and vitamin D supplementation to address osteoporosis, use of hip protectors, addressing medical issues such as hypotension and dizziness, and tapering, discontinuing or changing problematic medications. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuations (for example, if the individual continues to try to get up and walk without waiting for assistance.Monitoring and Follow-up: .2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will reevaluate the continued relevance of current interventions. 5. As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful.