Every finding on record at Evercare of Breese

Based on observation, interview, record review, and the facility failed to obtain necessary rehabilitation services for 2 (R40, R76) of 2 residents reviewed in the sample of 39. This failure resulted in R40 and R76 having a decline in function. Findings include:R40's face sheet documents admission date of 8/13/2024. Diagnosis includes Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Pulmonary Fibrosis, Acute and Chronic Respiratory Failure. R40's Minimum Data Set, MDS, dated [DATE] documents R40 has moderate cognitive disabilities. R40 requires partial/moderate assistance with mobility and transfers. R40 requires supervision/touching assistance with walking 10 feet. R40's care plan updated 2/20/2025 documents R40 has a range of motion, ROM, loss to all extremities related to Diagnosis: Cerebral Vascular Accident, CVA. R40 is at risk for decline related to comorbidities and would benefit from daily exercise to improve Activities of Daily Living, ADL, functioning. On 2/14/25 R40 continues to participate daily. Interventions include 1. Ask R40 to participate with exercise program. 2. Escort/assist/provide materials needed to perform exercises. 3. Bilateral lower extremity exercise with 2-3-pound weight times 20 reps in sitting. 4. Provide an entertaining and enjoyable environment. 5.Instruct/demonstrate exercise to range joints. 6. Praise/applause participation. 7. Provide verbal cues for safety issues. R40's care plan updated 2/20/2025 documents R40 has a self-care deficit in ambulation related to impaired mobility and Diagnosis: Cerebral Vascular Accident, CVA. On 2/14/25 Continues to participate daily, walking up to 150 feet with assistance and a walker. Interventions include 1. Explain procedure. 2. Apply gait belt. 3. Lock wheelchair brakes. 4. Assist to standing position. 5. Use wheeled walker - Ambulate from room to dining room to meals three times a day. 6. Encourage to ambulate full distance. 7. Allow for periods of rest if needed or appears tired. 8. May pull wheelchair behind for safety. 8. Praise all efforts.R40's Therapy to Nursing Recommendations dated 11/17/2025 documents Last therapy discharge date [DATE]. Restorative Recommendation active range motion. Leg strength with 2 pound weight. Cervical extension. Walking ambulate with wheeled walker with wheelchair to follow. R76's face sheet documents an admission date of 4/3/2025. Diagnosis includes Hemiplegia and Hemiparesis, Cerebral Infarction, Chronic Kidney Disease, Cerebral Infarction. R76's Minimum Data Set, MDS, dated [DATE] documents R76 has no cognitive deficits. R76 requires substantial assistance with mobility and transfers. R76's care plan updated 3/9/2026 documents Cerebral Vascular Accident, CVA: R76 requires healthcare monitoring related to diagnosis: CVA with Hemiparesis. She is at risk for impaired mobility and impaired communication related to effects of hemisphere damage on language or speech. R76's care plan updated 3/9/2026 documents active range of motion, ROM: R76 has a ROM loss to all extremities related to diagnosis: CVA with Hemiparesis. R76 is at risk for decline related to comorbidities and would benefit from daily exercise to improve Activities of Daily Living, ADL functioning. Interventions include: 1. Ask resident to participate with exercise program. 2. Escort/assist/provide materials needed to perform exercises. 3. Bilateral lower extremity exercise with 2-3-pound weight times 20 reps in sitting. 4. Provide an entertaining and enjoyable environment. 5. Instruct/demonstrate exercise to range joints. 6. Praise/applause participation. 7. Provide verbal cues for safety issues.R76's progress note dated 12/5/2025 at 3:12PM documents care plan was held for [NAME] on 12-4-25. [NAME] stated the only thing she would like to see more is restorative in the building so she can walk more I did explain that the aid can also walk her throughout the day. she had no other concerns at this time states she is happy here. R76 continues to be full code and being her own Power of Attorney, POA. R76 is doing well at the time her family visits when they are able. On 4/15/2026 at 3:06PM R76 stated her insurance pays for therapy, and she was receiving restorative therapy and has not received restorative therapy for the last 5 weeks. R76 stated the restorative therapist had to stop doing therapy and is now the transportation driver, due to the facility losing their driver. R76 stated she has not walked in month a month and she was walking 2-3 times a week with the restorative therapist. R76 stated she feels like she has declined since not having therapy and has begged the facility for therapy. R76 stated she will try to do some exercises on her own, but it is not the same. On 4/16/2026 at 9:15AM R40 stated V8 was walking me and doing leg lifts. I haven't gotten any walking in a long time now. V8 doesn't have time now because she drives the van. R40 denies anyone else providing restorative therapy. On 4/16/2026 at 9:20AM V11, Certified Nursing Assistant Coordinator, CNA, stated V8 used to do restorative and now she drives the van. We don't have anyone now for restorative therapy. On 4/16/2026 at 9:32AM V8, Transportation, stated I was the restorative aid before I became transportation driver. As far as I know no one is doing it. I have been driving the van and not doing restorative for a couple of months. On 4/16/2026 at 12:15PM V21, Regional MDS, stated We currently do not have a MDS coordinator in the facility. We also do not have a restorative nurse or restorative aid. We have a new program rolling out next week. On 4/16/2026 at 12:40PM V22, Certified Occupational Therapy Assistant, COTA, stated R40 was discharged from therapy to be picked up by restorative. He should be walking to the dining room and to his shower. That's all he wants. Not the whole hallway. I noticed a slight decline in R40 since he has not been walking. Facility policy dated 5/23/2025 states To promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. Includes, but not limited to, programs in walking/ mobility, dressing and grooming, eating and swallowing, transferring, bed mobility, communication, splint or brace assistance. Identify residents who currently have splints/braces or previous range of motion programs or those that have actual or potential limitations with ROM and/or pain. Develop and individualized program based on the resident's restorative needs, and include the restorative program on the care plan.

Based on observation, interview, and record review, the facility failed to properly transfer 4 of 4 (R33, R34, R16, R51) residents reviewed for falls in the sample of 39. This failure resulted in R16 and R34 sustaining fractures. Findings include: 1. R34's face sheet documents an admission date of 10/13/2023. Diagnosis includes Brachial Plexus Disorders, Aneurysm of the Ascending Aorta, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease. R34's Minimum Data Set, MDS, dated [DATE] documents R34 is severely cognitively impaired. R34's MDS dated [DATE] documents R34 requires substantial/maximum assistance for mobility and transfers. R34's care plan updated 4/14/2026 Risk for Falls. Falls documented on 4/1/2026 and 4/13/2026. Interventions dated 4/1/2026 document downgrade R34 to a two person assist and maintenance evaluated wheelchair and clears for safety. Intervention dated 4/13/2026 documents R34 lowered to the floor with a two-person transfer related to weakness. Immediate intervention R34 downgraded to a mechanical lift. Assist R34 with ambulation and transfers, utilizing therapy recommendations. Determine R34's ability to transfer. If fall occurs, alert provider.If R34 is a fall risk, initiate fall risk precautions. R34's Fall Risk Evaluation dated 9/27/2025 documents R34 is at risk for falls. Facility's initial Serious Injury Incident and Communicable Disease Report dated 4/2/2026 at 4:30PM documents R34 is a [AGE] year-old female who resides in the facility. She has been diagnosed with Brachial Plexus Disorders, Chronic Obstructive Pulmonary Disease, Abnormalities of Gait and Mobility, Vitamin D Deficiency, Chronic Kidney Disease Stage 3, Chronic Congestive Heart Failure, Polymyalgia Rheumatica, Hypomagnesaemia, Hypokalemia, Hyperlipidemia, anxiety Disorder, Major Depressive Disorder Recurrent among other disorders. She has a Brief Interview of Mental Stability, BIMS, of 5. On 4/1/2026 at approximately 4:30PM R34 sustained a witnessed fall in her room and was evaluated in house. Facility ordered an in-home Xray per Medical Doctors, MD, orders. The facility was notified that R34 has an acute versus subacute fracture of the acetabulum. There is a fracture of the inferior pubic [NAME]. The hip joint space is mildly and diffusely narrowed, and the femoral head has a normal contour. The adjacent soft tissues appear unremarkable. The visualized pelvis is intact. Prominent vascular calcification. Initial interventions: First aid provided. Assessments completed include vital signs, neuro checks, head to toe assessment, pain, fall risk assessment, and post-fall evaluation. Emergency Medical Services, EMS, call to transfer to the hospital for further evaluation and treatment upon positive Xray notification. Provider and family notified. Initial sent to Illinois Department of Public Health, IDPH, with final to follow within 5 business days. Investigation initiated. Investigation: A comprehensive investigation was conducted and revealed that on 4/1/2026 at approximately 4:30PM R34 was being assisted by 1 staff member to her wheelchair. R34 reached out to grab the arm rest and the wheelchair moved. R34 lost her balance and fell down on her bottom. R34's transfer status at the time of the incident was consistent with her assessed functional status and care plan. Per the aide, R34 showed no signs of weakness or unsteadiness. After the fall R34 denied any pain or dizziness. It was determined within the hour R34 began having increased discomfort, a bedside Xray was ordered, and the result was R34 has an acute versus subacute fracture of through the acetabulum. There is a fracture of the inferior pubic [NAME]. MD notified and an order received to send R34 to the Emergency Room, ER, for further testing and evaluations. Based on the results of the investigation the facility has found the R34 lost her balance when the wheelchair moved and was not the result of abuse. R34's progress noted dated 4/1/2026 at 4:51PM document Called to R34's room by Certified Nursing Assistant, CNA. R34 was lying on her left side on the floor. CNA explained that R34 was being transferred into her wheelchair from the bed, the wheelchair did not fully lock on the right side and the chair rolled backwards. R34 fell onto her buttock and left side. R34's progress notes dated 4/1/2026 at 5:31PM Fall was witnessed. Who witnessed fall: CNA Fall occurred in the R34's room. Activity at the time of fall: during a transfer. Reason for the fall was evident. Reason for fall: wheelchair moved back. Did an injury occur because of the fall: Yes. Injury details: Complains of hip pain. Did fall result in an ER visit/hospitalization: No. Provider: Nurse Practitioner, NP. Time notified: 4/01/2026 Notified of fall. R34's responsible party notified: Yes. Person contacted: Power of Attorney, POA. Details of notification: POA here at the facility. Date of R34's responsible party notification: 04/01/2026 at 5:04 PM Fall Details Note: Wheelchair did not fully lock.Contributing Factors: Recent change in environment: No. Was fluid spilled on floor: No. Clutter present on the floor: No. Floor mat was on floor: No. Poor lighting in the area: No. Bed was at an improper height: No. Other furniture involved: No. Wheelchair was involved in fall. Wheelchair was not unlocked at time of fall. Wheelchair footrest(s) were not in the way at the time of fall. Wearing glasses at the time of the fall: Yes. Footwear at time of fall: Shoes. R34 was not using cane/walker as instructed. R34 was not wearing oxygen as prescribed at time of fall. R34 was using incontinence supplies at the time of the fall. Incontinent at time of fall: No. Bedside call light on when R34 was found: No. Bathroom call light on when R34 was found: No. Personal alarm sounding when R34 found: No. Other Residents were not involved in fall. R34's progress notes dated 4/1/2026 at 5:54PM R34 complained of left hip discomfort status post fall. Call placed to on-call Nurse Practitioner, NP. Order received for left hip x-ray. R34's progress notes dated 4/1/2026 at 6:11PM documents Call placed to Xray company. They will be out tonight to do the left hip x-ray.R34's progress notes dated 4/1/2026 at Continues on fall flu. Complained of slight pain with transfers. X-ray completed, waiting on results. No bruising or signs of injury noted. Bed alarm on and functioning properly. Call light and personal items within reach.R34's progress notes dated 4/2/2026 at 6:15AM documents Received x-ray results. Impression showed comminuted fracture of the left hemipelvis including fracture through the acetabulum. Called and left message with V1. Called Regional Nurse and notified her of fracture. Assistant Director of Nursing, ADON, notified as well. Results faxed to Medical Director, MD, and sent on healthcare communication system. Verbal order received to send to Emergency Room, ER, to evaluate and treat. Called power of attorney, POA, and left voicemail. Called next contact and she agreed to send R34 to hospital for evaluation. Called Emergency Medical Services, EMS, and gave report with local hospital.R34's Xray results dated 4/2/2026 documents Examination Pelvis Indication: Left hip fracture. Findings: There is a cortical step off of the lacetabulum, suggestive of an acute accident tabular fracture. There is suggestion of a fracture involving the inferior left pubic ramus (arrow). There is subtle linear lucency underlying the left femoral head without definite cortical step off. Recommend CT Pelvis for further characterization. Vascular calcifications. Pelvic phlebolith.R34's After Visit Summary dated 4/2/2026 documents closed fracture of left hip, initial encounter. R34's progress notes dated 4/13/2026 at 5:20PM documents Fall Evaluation: History of falls (past 3 months): 1-2 falls in past 3 months. Level of consciousness / mental status: Intermittent confusion. Resident is chairbound / incontinent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses). Predisposing disease: 1-2 present. R34 had a change in condition in the last 14 days. Recent hospitalization history in last 30 days: Yes. Notes: R34 was hospitalized due to fracture. Gait / balance: Requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). Medication: Takes 1-2 of these medications (or medication classes) currently and / or within last 7 days. Fall Risk Score: 17.0. R34's progress notes dated 4/13/2026 at 4:53PM documents Staff were in R34's room assisting R34 into wheelchair for dinner. Staff assisting R34 with assist of 2 and use of gait belt. Mid transfer R34's knees buckled. Staff softly lowered R34 to the ground. Certified Nursing Assistants, CNAs, called this nurse to R34's room. R34 was sitting on floor with back on wheelchair seat when this nurse entered room. No complaints of pain or discomfort voiced. Range of motion within normal limits for R34. R34 assisted into wheelchair with staff assist of 3 and use of gait belt. R34 tolerated well. Power of Attorney, POA, called and message left for him to call facility back to update. Physician notified and requested an order for Therapy to evaluate and treat for safe transfers. R34 downgraded to a mechanical lift for safety. R34's progress notes dated 4/13/2026 at 5:20PM documents Fall Evaluation: History of falls (past 3 months): 1-2 falls in past 3 months. Level of consciousness / mental status: Intermittent confusion. Resident is chairbound / incontinent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses). Predisposing disease: 1-2 present. R34 had a change in condition in the last 14 days. Recent hospitalization history in last 30 days: Yes. Notes: R34 was hospitalized due to fracture. Gait / balance: Requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). Medication: Takes 1-2 of these medications (or medication classes) currently and / or within last 7 days. Fall Risk Score: 17.0 R34's progress notes dated 4/13/2026 at No signs of pain or discomfort related to recent fall/lowering to floor. R34 denies discomfort. No abnormal bruising or redness noted. In bed at this time with call light within reach. Will continue to monitor. On 4/15/2026 at 8:15AM V4, Registered Nurse, RN, stated I was here when (R34) fell. From what I understand (R34) was being transferred and there was a problem with the lock on the wheelchair. On 4/15/2026 at 11:35AM V5, Certified Nursing Assistant, CNA, stated I was working on 4/1/2026 when (R34) fell and broke hip. I was getting her out of bed. She was a 1 person assist. I made sure she had gripper socks on. I used a gait belt. I made sure the wheelchair was locked. I stood (R34) up and the wheelchair slid. (R34) ended up on the floor on her side. I got the nurse and the nurse assessed (R34). (R34) wanted to get to the dining room. She kept saying she was hungry. I was also working on 4/13/2026 when we had to lower (R34) to the floor. (V6) and I both went in to transfer (R34) from the bed to the wheelchair. We were told (R34) was now a 2 assist. We used a gait belt. We stood her up and her knees buckled. We set her slowly to the floor. We got the nurse and got (R34) up off the floor. (R34) is now a mechanical lift. On 4/15/2026 at 12:37PM V6, CNA, stated V5, CNA, and I attempted to transfer R34 from her bed to her wheelchair. We put a gait belt on her and when we stood up R34 she was dead weight. Her knees buckled and we lowered her to the floor. I helped transfer her before and she had done much better. Now R34 is a mechanical lift. On 4/16/2026 at 3:40PM V7, Nurse Practitioner, NP, stated I would expect residents to be transferred safely and equipment to be safe. 2. R16's Undated Face Sheet documents R16 was admitted to the facility on [DATE] and has a medical diagnosis of Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Anxiety Disorder, Hypertension, Muscle Weakness, Abnormalities of Gait and Mobility, Macular Degeneration, and Blindness One Eye and Low Vision Other Eye. R16's Minimum Data Set (MDS) dated [DATE] document R16 is moderately cognitively impaired, uses a wheelchair, needs substantial/maximal assistance with sitting to lying, lying to sitting on side of the bed, sitting to standing, and chair/bed to chair transfers. R16's Care Plan Date Initiated 4/29/2024 documents Fall: R16 has had an actual fall related to impaired mobility, use of psychotropic and anti-hypertensive medications and diagnosis Diabetes Mellitus II and Hypertension. R16's Care Plan Date Initiated 12/31/2024 documents Activities of Daily Living: R16 requires assist with daily care needs related to impaired mobility and diagnosis Diabetes Mellitus II. Interventions Date Initiated 12/31/2024 documents R16 transfers with 1 assist and gait belt. Interventions Date Initiated 2/19/2026 documents when ambulating with her walker please always assist her (R16) for safety. R16's Care Plan Date Initiated 12/31/2024 documents Transferring: R16 has a self care deficit in transferring related to impaired mobility. R16's Fall Risk Evaluation dated 2/2/2026 documents R16 had 1-2 falls in the past 3 months, has poor vision, a balance problem while standing and requires the use of assistive devices. R16's Incident Note dated 3/5/2026 at 4:30 PM documents (Certified Nursing Assistant) CNA walked res to dining room for supper with wheeled walker (W/W). CNA went to put pad alarm in stationary chair at table & res lost her balance & fell over the other way away from the cna. CNA called nurse to dining room to assess res. Res right (R) wrist swollen & painful. The Facility's Final Investigation dated 3/12/2026 documents Incident date 3/5/2026. On 3/5/26 at approx. 4:35 PM she (R16) sustained a witnessed fall in the dining room and was sent to the hospital for further evaluation and treatment. The facility was notified that she (R16) has a comminuted displaced fracture at the distal radial meta diaphysis with approximately 30 degrees of dorsal angulation. Mildly displaced ulnar styloid fracture. Investigation: Interviews revealed that on 3/25/26 at approximately 4:35 pm, R16 was being assisted by 1 staff member to the dining room with a gait and her walker. Upon arriving to her seat, the aide went to place the chair alarm in her chair and the resident lost her balance and fell in the direction away from the aide. Per the aide, the resident said, oh, oh and she was already falling and the aide was unable to keep her from falling. She was holding on to her walker at the time. Per the aide, the resident did not express any complaints of dizziness or pain during their walk to the dining room. The aide stated that R16 gait was steady, and showed no signs of weakness or unsteadiness. After the fall, the resident denied any dizziness, or pain prior to the fall and stated she just lost her balance. Root cause: resident lost her balance while standing. R16's Local Hospital Right Wrist X-Ray dated 3/5/26 documents impression: comminuted displaced fracture at the distal radial meta diaphysis with dorsal angulation. Mildly displaced ulnar styloid fracture. On 4/15/2026 at 2:46 PM V6, CNA, stated she assisted R16 to the dining room with a gait belt and walker. V6 stated she went to put R16's chair alarm in the dining room chair when R16 must have lost her balance. V6 stated she heard R16 say oh oh and R16 fell over. V6 stated R16 was holding onto the walker when V6 went to put the chair alarm in the chair. 3. On 4/16/2026 at 3:36 PM V26, CNA, observed walking R33 in hallway. V26 observed walking behind R33 holding R33's chair alarm. R33 observed walking using wheeled walker with no gait belt observed. R33's Undated Face Sheet documents R33 was admitted to the facility on [DATE] and has a medical diagnosis of Alzheimer's Disease, Hypertension, and Abnormalities of Gait and Mobility. R33's MDS dated [DATE] documents R33 is severely cognitively impaired, uses a walker, and needs substantial/maximal assistance with sitting to standing, chair/bed to chair transfers, and walking 10 feet. R33's Care Plan Date Initiated 2/12/2026 documents Activities of Daily Living: R33 requires assist with daily care needs related to impaired mobility, cognitive impairment and diagnosis: Alzheimer's. Interventions Date Initiated 2/12/2026 documents Transfers with 1 assist and gait belt. On 4/16/2026 at 3:40 PM V7, Nurse Practitioner (NP), stated she would expect staff to follow the Facility's Fall Policy and Transfer policy. V7 stated if a resident needs one assist to transfer and requires a gait belt, she expects staff to have a gait belt on the resident and to assist the resident while holding the gait belt. V7 stated she expects staff to stay with the resident while transferring and to use a gait belt when appropriate. On 4/17/2026 at 9:00 AM V3, Assistant Director of Nursing (ADON), stated she expects staff to follow the Facility's Fall Policy and Transfer Policy. V3 stated if a resident's care plan documents to use a gait belt with transfers, staff are absolutely expected to use a gait belt. V3 stated if a gait belt is used for a transfer, staff are expected to hold onto the gait belt in case a resident's leg starts to buckle, and staff would actively be there to assist. 4. R51 Facesheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, nondisplaced fracture of medial malleolus of right tibia, subsequent encounter for closed fracture with routine healing, syncope and collapse, and type two diabetes mellitus with diabetic chronic kidney disease. R51's MDS dated [DATE] documented she was dependent on staff for chair to bed to chair transfers. The facility's Serious Injury Incident and Communicable Disease Report dated 12/3/25 documented R51 was interviewed and voiced she felt that V20 (CNA) lowered her too quickly when transferring her with the full body mechanical lift. The report does not document any CNA assisting V20 during the transfer on 11/26/25. On 4/16/26 at 10:58 AM, V20 (prior CNA) stated the mechanical lifts are set to one speed, there isn't any way to go faster. V20 stated there wasn't anyone else with her when she used the full body mechanical lift on R51. V20 stated it was hard to find someone else to help, so she would use the full body mechanical lift alone and that would have been due to staffing. V20 stated there were frequent issues with staffing, it was a problem. V20 stated she was terminated and they said it was not a good fit. The facility's Transfer policy dated 6/1/25 documented the transferring needs of residents will be assessed on an ongoing basis and designated into categories: one person transfers with gait belt and mechanical lift (full body) with two caregivers. Facility Fall policy dated 6/1/2025 states To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. The facility will evaluate residents for their fall risk and develop interventions for prevention. Upon Admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls. The staff should not utilize a restraint to prevent falls unless they receive written documentation to support the use of the restraint. The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed.

Based on interview and record review, the Facility failed to ensure sufficient staffing to promote resident safety and highest practical well-being. This has the potential to affect all 80 residents living in the Facility. Findings include: 1-On 4/15/26 at 1:30 PM during the small group Resident Council Meeting, R51 stated sometimes call lights take a long time to get answered, and the other night was really bad. R51's Minimum Data Set (MDS) dated [DATE] documented R51 was cognitively intact and was dependent with transfers. Dependent was described as the helper does all effort and resident does none of the work or two or more helpers is required. The Facility's Incident Report regarding R51's allegation of rough handling during mechanical lift transfer documents V20, Former Certified Nursing Asssistant (CNA), was transferring R51 via mechanical lift when allegation was made. On 4/16/26 at 10:58 AM, V20 stated when she worked in the Facility it was hard to find someone else to help her with the mechanical lift due to short staffing, so she would use the full body mechanical lift alone. She stated staffing was always a problem at the Facility. 2-On 4/15/26 at 1:30 PM during the small group Resident Council Meeting, R79 stated night shift is bad about answering call lights and it usually takes about an hour. R79's MDS dated [DATE] documented R79 was cognitively intact. 3-4/14/26 at 9:23 AM, R86 stated the staff do the best they can, but they just need more help. Last night she had to wait 3 hours and 15 minutes to get her pain medication after pressing the call light. R86's MDS dated [DATE] documented R86 was cognitively intact. 4. R73's Undated Face Sheet documents R73 was admitted to the facility on [DATE] and has a medical diagnosis of Acute and Chronic Respiratory Failure with Hypoxia, Hypertension, Abnormalities of Gait and Mobility, and Difficulty in Walking. R73's Minimum Data Set (MDS) dated [DATE] documents R73 is cognitively intact, has an upper and lower extremity impairment on both sides, uses a wheelchair, is dependent on staff for toileting hygiene, showering/bathing, needs substantial/maximal assistance with sitting to standing, lying to standing, chair/bed to chair transfers, and is occasionally incontinent of urine. On 4/14/2026 at 9:10 AM R73 stated she has waited 2 hours and 15 minutes for staff to answer her call light and help her use the restroom because there is not enough staff. R73 stated she is glad that she only had to pee and if she needed to do something else it would have been a really bad situation. R73 stated the facility does not have enough staff to help provide timely care due to management issues. R73 stated she has had to wait over an hour and a half for her medications to be passed due to staffing issues. 5.R76's Undated Face Sheet documents R76 was admitted to the facility on [DATE] and has a medical diagnosis of Hemiplegia and Hemiparesis Following Nontraumatic Intracerebral Hemorrhage Affecting Left Dominant Side, Type 2 Diabetes Mellitus, Nontraumatic Intracranial Hemorrhage, Hypertension, Chronic Pain Syndrome, Left Ankylosis, and Epilepsy. R76's Minimum Data Set (MDS) dated [DATE] documents R76 is moderately cognitively impaired, has a lower extremity impairment on both sides, uses a wheelchair, is dependent on staff for toileting hygiene, needs substantial/maximal assistance with sitting to standing, and chair/bed to chair transfers. On 4/15/2026 at 3:06 PM R76 stated the staff the facility does have is good but the number of staff the facility has is bad. R76 stated the facility needs to budget for more CNA staff. R76 stated the staff the facility does have work their butts off and cannot provide great or timely care due to the lack of staff. R76 stated the number of residents to one CNA is inexcusable. R76 stated call lights build up because staff cannot answer them timely because there is not enough staff. R76 stated the CNAs are spread too thin and cannot provide the best of care. R76 stated she has waited more than a half hour on the day and evening shift and more than 45 minutes on the night shift for staff to answer her light. R76 stated she was receiving restorative therapy and due to staffing issues, she no longer receives therapy due to the restorative aide now doing the transportation job. R76 stated the facility keep accepting new residents but is not hiring more staff to provide care. On 4/14/26 at 11:08 AM, V10, Ombudsman, stated residents' biggest complaints are regarding short staffing and about having to wait hours for help when pressing their call lights. She stated residents report medications are often given late due to staffing. On 4/15/26 at 2:50 PM, V6, Certified Nursing Assistant (CNA), stated it usually takes at least 15 minutes for staff to answer call lights and residents may wait longer than that. On 4/16/26 at 3:00 PM, V25, CNA, stated sometimes it is hard to meet resident needs in a timely manner. The new CNA's only get three days of training and sometimes they are not up to par, so residents are left waiting longer for care. The Facility's Resident Council Memorandums dated 5/20/25, 6/16/25, 8/18/25, 9/15/25, 10/24/25, 11/17/25, and 12/18/25 all document call light wait times as a problem. On 4/16/26 at 3:12 PM, V3, Assistant Director of Nursing (ADON)/Infection Preventionist (IP), stated they are occasionally short on CNA's, so residents may have to wait to get care. The Facility has been trying to get more help but it is difficult getting them in the door. On 4/17/26 at 9:00 AM, V3 stated she was working as a floor nurse today. On 4/17/26 at 1:00 PM, V1, Administrator, stated the Facility is trying to hire more staff of its own, but they do need to use agency staffing to make sure they are fully staffed. She feels resident needs are being met in a timely fashion but thinks every resident living in a Facility would tell you they need more staff. The Facility's Transfers – Manual Gait Belt and Mechanical Lifts Policy reviewed 6/1/25 documents mechanical lift requires two caregivers. The Facility's Staffing Policy dated 12/5/26 stated it was the policy of the Facility to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychological well-being of each resident. The Facility's Long Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 4/14/26 documents there are 80 residents living in the Facility.

Based on interview and record review, the Facility failed to ensure call lights were answered in a timely fashion for 5 of 5 residents (R51, R79, R86, R73, R76) reviewed for resident rights in the sample of 39.Findings include: 1-On 4/15/26 at 1:30 PM during the small group Resident Council Meeting, R51 stated sometimes call lights take a long time to get answered, and the other night was really bad. R51's Minimum Data Set (MDS) dated [DATE] documented R51 was cognitively intact. 2-On 4/15/26 at 1:30 PM during the small group Resident Council Meeting, R79 stated night shift is bad about answering call lights and it usually takes about an hour to get help. R79's MDS dated [DATE] documented R79 was cognitively intact. 3-4/14/26 at 9:23 AM, R86 stated last night she had to wait 3 hours and 15 minutes to get help after pressing the call light. R86's MDS dated [DATE] documented R86 was cognitively intact. 4.R73's Undated Face Sheet documents R73 was admitted to the facility on [DATE] and has a medical diagnosis of Acute and Chronic Respiratory Failure with Hypoxia, Hypertension, Abnormalities of Gait and Mobility, and Difficulty in Walking. R73's Minimum Data Set (MDS) dated [DATE] documents R73 is cognitively intact, has an upper and lower extremity impairment on both sides, uses a wheelchair, is dependent on staff for toileting hygiene, showering/bathing, needs substantial/maximal assistance with sitting to standing, lying to standing, chair/bed to chair transfers, and is occasionally incontinent of urine. On 4/14/2026 at 9:10 AM R73 stated she has waited 2 hours and 15 minutes for staff to answer her call light and help her use the restroom because there are not enough staff. R73 stated she is glad that she only had to pee and if she needed to do something else it would have been a really bad situation. R73 stated the facility does not have enough staff to help provide timely care and answer call lights promptly due to management issues. 5.R76's Undated Face Sheet documents R76 was admitted to the facility on [DATE] and has a medical diagnosis of Hemiplegia and Hemiparesis Following Nontraumatic Intracerebral Hemorrhage Affecting Left Dominant Side, Type 2 Diabetes Mellitus, Nontraumatic Intracranial Hemorrhage, Hypertension, Chronic Pain Syndrome, Left Ankylosis, and Epilepsy. R76's Minimum Data Set (MDS) dated [DATE] documents R76 is moderately cognitively impaired, has a lower extremity impairment on both sides, uses a wheelchair, is dependent on staff for toileting hygiene, needs substantial/maximal assistance with sitting to standing, and chair/bed to chair transfers. On 4/15/2026 at 3:06 PM R76 stated the staff the facility has is good, but the number of staff is bad. R76 stated the call lights build up because staff cannot answer them timely because there is not enough staff. R76 stated the CNA's are spread too thin and cannot provide the best of care. R76 stated she has waited more than a half hour on the day and evening shift and more than 45 minutes on the night shift for staff to answer her light. On 4/14/26 at 11:08 AM, V10, Ombudsman, stated residents complain about having to wait hours for help when pressing their call lights. On 4/15/26 at 2:50 PM, V6, Certified Nursing Assistant (CNA), stated it usually takes at least 15 minutes for staff to answer call lights and residents may wait longer than that. The Facility's Resident Council Memorandum dated 5/20/25 documents, Long wait times for call lights to be answers {sic}. Residents think its worse on weekends? The Facility's Resident Council Memorandum dated 6/16/25 documents, Call light wait times are still taking a while to be answered. The Facility's Resident Council Memorandum dated 8/18/25 documents, Resident complaining of call lights being turned off before they are helped with what they had the light on for. The Facility's Resident Council Memorandum dated 9/15/25 documents, Residents state they are waiting long periods of time for call lights to be answered. The Facility's Resident Council Memorandum dated 9/15/25 documents, Call lights being turned off before residents are helped with what they need continue to be an issue. The Facility's Resident Council Memorandum dated 10/24/25 documents, Call lights being turned off before residents are helped continue to be an issue. Also long wait times for call lights to be answered. The Facility's Resident Council Memorandum dated 11/17/25 documents, Long call light wait times and long wait times to get off the toilet. The Facility's Resident Council Memorandum dated 12/18/25 documents, Residents are saying call light wait times take up to 45 minutes, long wait times to get off the toilet. On 4/16/26 at 1:13 PM, V1, Administrator, stated call lights should be answered as quickly as possible. She stated five to seven minutes would be ok, but it should not take hours. The Facility's Undated Call Light Policy documents call lights will be answered in a timely manner.

Based on interview and record review the facility failed to ensure 4 of 4 (R34, R43, R67, R71)) residents reviewed for immunizations in the sample of 38, received the education addressing the benefits and risks and/or had the opportunity to receive Center for Disease Control, CDC recommended immunizations. Findings Include:Review of R34's Face Sheet documents an admission date of 10/13/2023 and documents a birthdate of 3/14/1930. Diagnosis include Brachial Plexus Disorders, Aneurysm of the Ascending Aorta, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease. Review of R43's Face Sheet documents an admission date of 6/2/2024 and birthdate of 3/14/1930. Diagnosis includes Cerebral Infarction, Peripheral Vascular Disease, Chronic Kidney Disease, Hypertension. Review of R67's Face sheet documents an admission date of 6/5/2024 with a birthdate of 11/25/1935. Diagnosis includes Osteoarthritis, Type 2 Diabetes, Heart Failure, and Dysphagia. Review of R71's Face sheet documents an admission date of 9/1/2025 and a birthdate 12/23/1945. Diagnosis includes Acute Respiratory Failure, Encephalopathy, Seizures, Dementia. Review of R34's, R43's, R67's, R71's, Clinical Record did not indicate that residents had received the education addressing the benefits and risks or had the opportunity to receive or decline a dose of the 20-valent pneumococcal, 21-valent, PCV15-valent, PCV conjugate vaccine23-valent pneumococcal polysaccharide vaccine. On 4/16/26 and 4/17/26, proof of education and vaccination and/or declination for R34, R43, R67, and R71 were requested multiple times.On 4/17/26 at 8:30 AM, the Facility's policy regarding Pnuemococcal vaccination was requested from V1, Administrator, and V27, Regional Nurse Consultant.On 4/17/26 at 9:08 AM, V27 stated they have reached out to the company that provides the vaccination to see if they would have this documentation. Review of the undated facility policy titled, Influenza/Pneumococcal/RSV Immunizations stated, The facility shall provide pertinent information about the significant risks and benefits of vaccines to residents (or resident's legal representative); for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy. Review of information found at Expanded Recommendations for Use of Pneumococcal Conjugate Vaccines Among Adults Aged 50 Years: Recommendations of the Advisory Committee on Immunization Practices - United States, 2024 | MMWR documents Before October 2024, the Advisory Committee on Immunization Practices (ACIP) recommended use of a pneumococcal conjugate vaccine (PCV) for all adults aged 65 years, as well as for those aged 19-64 years with risk conditions for pneumococcal disease who have not received a PCV or whose vaccination history is unknown. Options included either 20-valent PCV (PCV20; Prevnar20; [NAME] Pharmaceuticals) or 21-valent PCV (PCV21; CAPVAXIVE; Merck Sharp & Dohme) alone or 15-valent PCV (PCV15; VAXNEUVANCE; Merck Sharp & Dohme) in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23; Pneumovax23; Merck Sharp & Dohme). There are additional recommendations for use of PCV20 or PCV21 for adults who started their pneumococcal vaccination series with 13-valent PCV (PCV13; Prevnar13; [NAME] Pharmaceuticals). The ACIP Pneumococcal Vaccines Work Group employed the Evidence to Recommendations framework to guide its deliberations on expanding the age-based PCV recommendation to include adults aged 50-64 years. On October 23, 2024, ACIP recommended a single dose of PCV for all PCV-naive adults aged 50 years. Recommendations for PCVs among adults aged 19-49 years with risk conditions and PCV13-vaccinated adults have not changed from previous recommendations. This report summarizes evidence considered for these recommendations and provides updated clinical guidance for use of PCV.

Based on interview and record review, the Facility failed to provide Covid-19 vaccine education and offer Covid-19 vaccination to 5 of 5 residents (R34, R49, R50, R67, R71) reviewed for immunization in the sample of 39.Findings include: 1-R34's Face Sheet documents R34 was admitted to the facility on [DATE]. R34's Immunization Report does not document Covid-19 vaccination or declination. 2-R49's Face Sheet documents R49 was admitted to the facility on [DATE]. R49's Immunization Report does not document Covid-19 vaccination or declination. 3-R50's Face Sheet documents R50 was admitted to the facility on [DATE]. R50's Immunization Report documents R50 received a Covid-19 vaccine on 3/4/21. There was no documentation that R50 was offered or given a Covid-19 vaccine since 3/4/21. 4-R67's Face Sheet documents R67 was admitted to the facility on [DATE]. R67's Immunization Report documents R67 received a Covid-19 vaccine on 3/7/23. There was no documentation that R67 was offered or provided a Covid-19 vaccine since 3/7/23. 5-R71's Face Sheet documents R71 was admitted to the facility on [DATE]. R71's Immunization Report does not document Covid-19 vaccination or declination. On 4/16/26 and 4/17/26, documentation of Covid-19 vaccine education and documentation of vaccination and/or declination for R34, R49, R50, R67, and R71 were requested multiple times. On 4/17/26 at 9:08 AM, V27, Regional Nurse Consultant, stated they have reached out to the company that provides the vaccination to see if they would have this documentation but did not have that information yet. On 4/17/26 at 1:00 PM, no Covid-19 vaccination documentation was received from the Facility. On 4/17/26 at 10:37 AM, V27 stated she would expect the Facility to follow its policy regarding vaccinations. The Facility's Undated COVID-19 Guidelines - Residents and Employees Policy documents the facility shall provide pertinent information about the significant risks and benefits of the vaccine to residents (or resident's legal representative).

Based on interview and record reviews, the facility failed to revise resident's care plans with progressive interventions for 2 of 8 (R2, R22) residents investigated for falls in a sample of 39.Findings include:R2's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE].R2's EMR dated 1/7/26 documents a diagnosis of acute hematogenous osteomyelitis, left ankle and foot.R2's EMR dated 3/8/25 documents a diagnosis of other abnormalities of gait and mobility.R2's MDS (Minimum Data Set) dated 3/3/26 documents a BIMS (Brief Interview for Mental Status) score of 8 out of 15. The MDS documents that the resident is dependent for roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer.R2's Care Plan dated 1/1/26 documents Falls: (R2) has had actual falls related to impaired mobility and DX (Diagnosis): DM II Diabetes Mellitus type 2).R2's Incident Note dated 6/27/25 at 12:59 PM documents This nurse was notified by staff that resident had slipped out of wheelchair in the dining room onto the floor et hit head. No injuries noted at this time, ROM (Range of Motion) WNL (within normal limits). Neuros initiated at this time, daughter notified of incident, MD (Medical Director) notified via fax et DON (Director of Nursing) notified via (phone app). Incident report completed per facility protocol.Facility's intervention for this fall was to Dycem placed on wheelchair under (mechanical) sling.R2's Post Fall Evaluation dated 3/12/26 at 7:22 AM documents Fall Details: Fall was witnessed. Fall occurred elsewhere. Other fall location: while out at appointment/Activity at the time of fall: sitting in wheelchair being transported The reason for the fall was not evident. Did an injury occur as a result of the fall: Yes. Injury details: skin tear to BLE (bilateral lower extremities) Did fall result in an ER (Emergency Room) visit/hospitalization: No. Provider: (V28), (V29) Time notified: 03/11/2026 New orders received; See Provider order sheet. Resident's responsible party notified: Yes. Person contacted: (V30) Details of notification: Left a message for her to call the facilty Date of Resident's responsible party notification: 03/11/2026 3:15 PM,Facility's intervention for this fall was to Resident to use dycem between resident and (mechanical) sling during out of facility transports for additional safety.R22's EMR undated documents that the resident was admitted to the facility on [DATE].R22's EMR dated 4/3/25 documents a diagnosis of chronic obstructive pulmonary disease, unspecific.R22's EMR dated 4/3/25 documents a diagnosis of muscle weakness (generalized).R22's MDS dated [DATE] documents a BIM score of 6 out of 15. The MDS documents that the resident requires substantial/maximal assistance for roll left and right. The MDS documents that the resident is dependent for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer.R22's Care Plan undated documents Falls: Dale is at risk for falls related to impaired mobility, use of anti-hypertensive medication and Dx (Diagnosis): DM II (Diabetes Mellitus type 2) and Hypertension.R2's Incident Note dated 12/22/2025 at 12:15 PM documents Res (resident) in room yelling help. Entered room & found res laying on floor between bed & wall. When asked how res got on floor, res stated that he was trying to get something out of his drawer in his nightstand and slid off of the bed. Res assessment completed, able to move all extremities. Denies any pain/discomfort. No injuries noted. Neuro checks initiated due to un-witnessed fall & WNL (within normal limits) for res. VS (vital signs) 98.7-74-20-128/60-97% RA (room air). Res assisted back into bed with (mechanical) lift & assist of 2 staff members. MD updated. Res is his own POA (Power of Attorney).Facility's intervention for this fall was IDT met and fall intervention is for room to be arranged more to (R22)'s liking and to maximize safety.R22's Health Status Note dated 1/9/2026 at 6:39 AM documents resident heard yelling for help, CNA (Certified Nursing Aid) saw resident from hallway sliding off edge of bed, unable to get to resident in time. resident slid from bed onto floor mat on knees. resident was assessed and no injuries sustained, denies c/o (complaint of) pain. resident assisted back into bed. ROM WNL for this resident. VS 98.0-74-18-135/58-97% on room air. resident stated he was sitting on edge of bed and attempted to reach for bedside dresser to get a piece of candy from the drawer when he started to slide. due to bilateral BKA Below the knee amputation), resident was unable to stop self from sliding from edge of bed. Resident educated to call for assist for items not in immediate reach. bedside dresser moved closer to be within resident's reach. MD notified of above.Facility's intervention for this fall was IDT met on fall. (R22)'s room furniture re-arranged for better accommodation to space and safety, with the consent of the client.On 4/17/26 at 9:58 PM, V31, [NAME] President of Clinical Operations stated that care plan interventions should be progressive.Facility's Care Planning policy dated 9/2/25 documents Purpose: to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. V. The IDT will revise the Comprehensive Care Plan as needed at the following intervals: A. Per RAI Schedules. B. As dictated by changes in resident condition. C. in preparation for discharge. D. to address changes in behavior and care; and E. Other times as appropriate or necessary.

Based on observation, interview, and record review, the facility failed to investigate, recognize, isolate, track/trend and treat a scabies outbreak per current standards of practice for 5 of 5 residents (R1, R2, R6, R7, and R10) in a sample of 13 reviewed for infection control. Applying the reasonable person concept, a reasonable person would have extreme discomfort due to itching and psychosocial distress issues due to anxiety, embarrassment, shame, or even isolation. This failure has the potential to affect all 69 residents residing in the facility. Findings Include:1. R1's Face Sheet, print date of 09/30/25, documented R1 has diagnoses of but not limited to Dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and transient cerebral ischemic attack. R1's Minimum Data Set (MDS), dated [DATE], documented R1 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 13 out of 15 and she requires assistance with her activities of daily living (ADLs).R1's Care Plan, admission date of 03/11/23, documented the resident has a rash r/t (related to) possible scabies and will be treated as such, the resident will have no complications from rash through the review date, the resident will have no s/sx (signs/symptoms) of infection of the rash through the review date, and the resident's rash will heal by review date (date initiated: 09/29/2025). Goal: The resident will have no complications from rash through the review date. Interventions include but not limited to: Give anti-pruritic medication as ordered by medical doctor (MD), Monitor/document side effects and effectiveness, monitor skin rashes for increased spread or signs of infection, and seek medical attention if skin becomes bloody or infected.R1's Physician's Orders, dated 01/04/2024, documented Free of signs and symptoms of communicable diseases.R1's Physician's Orders, dated 01/30/25, weekly skin assessment, complete assessment in electronic medical record (EMR) and document any changes, every day shift every Friday for skin care.R1's Physician's Orders, dated 09/24/25, documented Elimite External Cream 5% (Permethrin) Apply to whole body neck to toes topically at bedtime for skin care until 09/25/25 1:59 PM and remove per schedule. R1's Facility Nursing Home certified nursing assistant (CNA) shower sheets for August 2025 and September 2025 were reviewed and documented the following skin issues:On 08/19/25, documented R1 had scabs to her neck and right arm. On 09/25/25, documented R1 was treated prophylactically for rash.R1's Skin Checks, for August 2025 and September 2025 were reviewed and documented the following skin issues: On 09/24/25 at 1:34 PM, Skin issue: New issue R1 has a generalized rash.R1's Progress Notes, documented the following: On 09/12/25 at 12:23 PM, R1 has no new skin issues.On 09/19/25 at 1:36 PM, has no new skin issues documented. On 09/22/25 at 10:26 AM, R1's son at the facility to visit and asking the nurse who he needs to speak to about the itchy rash on R1's limbs. R1 and her son were directed to V9, Infection Control Preventionist (ICP) for further instructions.On 09/25/25 at 9:42 AM, documented Note Text: Resident had a skin check done on 09-24 due to a small outbreak of scabies in the facility. Resident does have a small rash and will be treated, and all lines will be washed, family was notified and is fine with the treatment. On 09/26/25 at 11:58 AM, documented R1 has no new skin issues identified.On 09/29/25 at 1:25 PM, R1 had redness and little red spots to both of her arms.On 09/29/25 at 1:25 PM, R1 said she had a rash on her arms, and it was itching. She was seen by the Nurse Practitioner (NP) V12 and was treated for the rash. 2. R2's Face Sheet, print date of 09/30/25, documented R2 has diagnoses of but not limited to Parkinson's disease without dyskinesia, Type II diabetes mellitus (DM) with diabetic polyneuropathy, and dementia. R2's MDS, dated [DATE], documented R2 is severely cognitively impaired with a BIMS of 04 out of 15 and unable to be interviewed. She requires substantial/maximal assistance with her ADLs. R2's Care Plan, dated 08/30/24, documented date initiated on 09/29/25, the resident has a rash r/t possible scabies and will be treated as such. Goal: The resident will have no complications from rash through the review date, the resident will have no s/sx of infection of the rash through the review date, and the resident's rash will heal by review date. Interventions include but not limited to Avoid scratching and keep hands and body parts from excessive moisture, give anti-pruritic medication as ordered by MD. Monitor/document side effects and effectiveness, and monitor skin rashes for increased spread or signs of infection.R2's Physician's Orders, dated 07/01/25, documented skin checks-perform upon admission and weekly thereafter, every day shift every Thursday for facility protocol, complete skin assessment under assessment tab.R2's Physician's Orders, dated 09/11/25, documented Triamcinolone Acetonide External Cream 0.1% (topical) Apply to trunk and extremities topically every day and night shift related to Allergy status to unspecified drugs, medicaments ad biological substances discontinue (D/C) when rash is gone.R2's Physician's Orders, dated 09/24/25, documented Elimite External Cream 5% (Permethrin) Apply to whole body neck to toes topically at bedtime for skin care until 09/25/25 13:59 (1:59 PM) and remove per schedulR2's Facility Nursing Home CNA shower sheet, for August 2025 and September 2025 were reviewed and documented the following skin issues:On 08/10/25, rash to left abdomen and left back areas. Reported by V10, CNA. On 08/21/25, discoloration to bilateral tops of hands.On 08/25/25, rash to front chest area.On 08/28/25, rash to front upper chest and back upper chest. In the comments/follow up section by the nurse it documented: Red rash across chest and upper back.On 09/01/25, rash to chest and upper back area.On 09/04/25, rash to chest and upper back area.On 09/08/25, discoloration to bilateral hands.On 09/11/25, rash to chest, back, and front of legs. On 09/15/25, rash to chest area.On 09/18/25, rash to chest, upper back, and abdomen areas.On 09/22/25, rash to front and back areas.On 09/25/25, in the comment section it documented scratching everywhere on upper body. On 09/29/25, rash/spots chest area. R2's Skin Checks, for August 2025 and September 2025 were reviewed and documented the following skin issues:On 09/11/25 at 12:41 PM, New skin issue: Rash, in-house acquired. Skin notes: Rash continues to body. Continuing Triamcinolone Acetonide External Cream 0.1% to trunk and extremities topically every morning and at bedtime. On 09/18/25 at 2:43 PM, Needs Review: Rash, in-house acquired. Skin issues notes: rash remains, treatment (tx) in place.R2's Progress Notes, were reviewed and documented the following:On 09/04/25 at 10:16 AM, documented Skin Check, No new skin issues.On 09/11/25 at 12:41 PM, documented Skin Check, Skin: Skin warm and dry, skin color within normal limits (WNL) and turgor is normal. On 09/17/25 at 11:16 PM, documented Type: Skin/wound note, late entry Note Text: Notified nurse practitioner (NP) about recommendations for rash to try Triamcinolone 0.1% and Cetaphil or Eucerin over the counter (OTC) twice a day (BID). On 09/18/25 at 2:43 PM, documented Skin Check Skin: Skin warm and dry, skin color within normal limits (WNL) and turgor is normal. Skin Issues: Skin issue has not been evaluated. Location: Generalized. Issue type: Rash. Rash continues to body. Continuing Triamcinolone Acetonide External Cream 0.1% to trunk and extremities topically every morning and at bedtime.On 09/24/25 at 10:01 PM, documented Note Text: Triamcinolone Acetonide External Cream 0.1% Apply to trunk and extremities topically every day and night shift related to allergy status to unspecified drugs, medicaments and biological substances. Discontinue (D/C) when rash is gone, other cream applied.On 09/25/25 at 10:24 AM, documented Note Text: Resident had a skin check done on 09-24 due to a small outbreak of scabies in the facility. Resident does have a small rash and will be treated, and all lines will be washed, family was notified and is fine with the treatment. 3. R6's Face Sheet, print date of 09/30/25, documented R6 has diagnoses of but not limited to Parkinson's disease with dyskinesia, vascular dementia, and cerebral infarction due to embolism of basilar artery.R6's MDS, dated [DATE], documented R6 is severely cognitively impaired with a BIMS of 07 out of 15 and he requires substantial/maximal assistance or is dependent on staff for most of his ADLs. R6's Care Plan, admission date of 01/07/25, documented the resident (R6) has a rash related to possible scabies and will be treated as such (Date Initiated: 09/30/25). Goal: Resident will have no complications from rash through the review date, the resident will have no s/sx of infection of the rash through the review date, and the resident's rash will heal by review date. Interventions include but not limited to: Give anti-pruritic medication as ordered by MD, monitor skin rashes for increased spread or signs of infection, and seek medical attention if skin becomes bloody or infected. R6's Physician's Orders, dated 01/07/2025, documented Free of signs and symptoms of communicable diseases. R6's Physician's Orders, dated 07/07/25, documented Skin Checks-Perform upon admission and weekly thereafter, every day shift every Wednesday for facility protocol complete skin assessment under assessment tab. R6's Physician's Orders, dated 09/17/25, documented Apply to rash areas Triamcinolone cream and mix with Cetaphil/Eucerin cream (OTC) BID every day and night shift for skin care. R6's Physician's Orders, dated 09/24/25, documented Elimite External Cream 5% (Permethrin) Apply to whole body neck to toes topically at bedtime for skin care until 09/25/25 1:59 PM and remove per schedule.R6's Facility Nursing Home CNA shower sheet, for August 2025 and September 2025 were reviewed and documented the following skin issues:On 08/09/25, Rash to chest area.On 08/13/25, Communication section: Red bumps all over body/mostly on left (Lt.) upper arm.On 08/23/25, Rash to front/back areas. Anti-itch cream applied.On 08/27/25, Rash to front and back areas and scratches to his front area.On 08/30/25, Rash to Right (Rt.) and Lt. upper chest/arm, left lower arm, Rt. upper back and Rt. lower back.On 09/03/25, Rash to front and back areas.On 09/06/25, Rash to front/back area and left back of leg.On 09/10/25, Rash to front/back area, left back of leg, and scratches to leg.On 09/17/25, Rash to front upper chest, arms, upper legs, abdomen, and scratches to Rt. upper back and left calf area.On 09/20/25, Rash front/back, upper and lower torso, bilateral lower extremities, and scratches to Rt. shoulder and Lt. lower leg. On 09/24/25, Rash entire front, Rt. shoulder scratches, and scratches to Lt. lower leg. On 09/27/25, Rash to his Rt. and Lt. arms, chest, abdomen, bilateral legs and feet, and his back.R6's Skin Check, dated 08/09/25 2:53 PM, documented Skin Issues Note Rash noted to upper chest, physician notified, awaiting response.R6's Skin Check, dated 08/13/25 at 10:58 AM, documented Skin Issues Note Resident is breaking out with red rash, has scratches on left upper arm from itching. New order of Benadryl ointment to begin upon arrival.R6's Skin Check 08/27/25 at 6:06 PM, documented R6 had no skin issues.No September 2025 Skin checks for R6 were provided after requested on 09/30/25 and 10/16/2025.R6's Progress Notes, were reviewed and documented the following skin issues:On 09/17/25 at 11:16 AM, documented Type: Skin/Wound Note Late Entry, Note Text: Notified NP about recommendations for rash to try Triamcinolone 0.1% and Cetaphil or Eucerin OTC BID, Orders entered. On 09/24/25 at 1:34 PM, documented Type: Skin Check. Skin warm and dry, skin color WNL and turgor is normal. No new skin issues identified. Skin issues: New skin issues. Location: Generalized. Issue type: Rash. Wound acquired in-house. Skin issue note: scattered rash to back/torso. TMC (Triamcinolone)/Cetaphil/Eucerin cream mix. On 09/25/25 at 9:53 AM, documented Resident had a skin check done on 09-24 due to a small outbreak of scabies in the facility. Resident does have a small rash and will be treated, and all lines will be washed, family was notified and is fine with the treatment. 4. R7's Face Sheet, print date of 09/30/35, documented R7 has diagnoses of but not limited to Multiple sclerosis, need for assistance with personal care, dementia, and hypertension (HTN).R7's MDS, dated [DATE], documented R7 is severely cognitively impaired with a BIMS of 05 out of 15 and she requires substantial/maximal assistance with most of her ADLs.R7's Care Plan, admission date of 05/10/24, documented the resident (R6) has a rash related to possible scabies and will be treated as such (Date Initiated: 09/30/25). Goal: Resident will have no complications from rash through the review date, the resident will have no s/sx of infection of the rash through the review date, and the resident's rash will heal by review date. Interventions include but not limited to: Give anti-pruritic medication as ordered by MD, monitor skin rashes for increased spread or signs of infection, and seek medical attention if skin becomes bloody or infected.R7's Physician's Orders, dated 09/02/25, documented Free of signs and symptoms of communicable diseases, Skin Checks-Perform upon admission and weekly thereafter, every day shift every Thursday for facility protocol complete skin assessment under assessment tab, and Benadryl itch stopping external cream 1-0.1% (Diphenhydramine-Zinc Acetate) Apply to Pruritus areas typically every 12 hours as needed for itching.R7's Physician's Orders, dated 09/11/25, documented Monitor rash to chest, back, and BIL (bilateral) front and back of legs until healed every shift for skin care.R7's Physician's Orders, dated 09/17/25, documented Apply to rash areas Triamcinolone cream mixed with Cetaphil/Eucerin cream BID every day and night shift for skin care.R7's Physician's Orders, dated 09/24/25, documented Elimite External Cream 5% (Permethrin) Apply to whole body neck to toes topically at bedtime for skin care until 09/25/25 1:59 PM and remove per schedule.R7's Facility Nursing Home CNA shower sheet, for August 2025 and September 2025 were reviewed and documented the following skin issues:On 08/04/25, Rash with scratches to whole front upper torso, rash to both upper legs, and rash to entire back area.On 08/07/25, Red rash to entire torso (front/back) and both upper (thigh) legs.On 08/11/25, Rash to upper torso front and back.On 08/14/25, Rash to upper torso and bilateral upper legs.On 08/18/25, Rash to upper chest, abdomen, bilateral arms, bilateral thighs, and scratches to bilateral legs.On 08/21/25, Rash to upper torso and both upper legs.On 08/25/25, Rash to upper torso and bilateral upper legs.On 08/28/25, Rash to upper torso.On 09/04/25, Rash to torso front and back and both legs front and back.On 09/08/25, Rash to entire body.On 09/11/25, Rash to entire body. (Orders placed to monitor rash every (Q) shift.)On 09/15/25, 09/18/25, and 09/22/25, Rash to entire body.On 09/26/25, Rash to abdomen, back and both legs.R7's Skin Checks, documented the following skin issues:On 08/18/25 at 10:00 AM, documented new skin issue: Generalized rash and to apply as needed (PRN) cream. On 08/25/25 at 9:51 AM, documented evaluation generalized rash.On 09/02/25 at 2:29 PM, documented skin issue needs reviewed, generalized rash.On 09/11/25 at 12:36 PM, documented evaluated, generalized rash is stable.On 09/18/25 at 2:41 PM, documented needs reviewed generalized rash. R7's Progress Notes, were reviewed and documented the following:On 09/02/25 at 2:49 PM, documented Skin Check generalized rash. On 09/11/25 at 12:36 PM, documented Skin Issues: Skin issue has been evaluated. Generalized rash.On 09/17/25 at 11:15 AM, documented Late Entry Note Text: Notified NP about recommendations for rash to try Triamcinolone 0/1% and Cetaphil or Eucerin OTC BID. Orders entered. On 09/18/25 at 2:41 PM, documented Skin Check Skin Issues Note: sporadic rash noted to body, tx in place.On 09/25/25 at 9:30 AM, documented Resident had a skin check done on 09-24 due to a small outbreak of scabies in the facility. Resident does have a small rash and will be treated, and all lines will be washed, family was notified and is fine with the treatment. 5. R10's Face Sheet, print date of 09/30/25, documented R10 has diagnoses of but not limited to hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side, type II DM, epilepsy, and HTN.R10's MDS, dated [DATE], documented R10 is cognitively intact with a BIMS of 14 out of 15 and she requires substantial/maximal assistance or is dependent on staff for help with her ADLs.R10's Care Plan, admission date of 04/03/25, documented the resident (R10) has a rash related to possible scabies and will be treated as such (Date Initiated: 09/30/25). Goal: Resident will have no complications from rash through the review date, the resident will have no s/sx of infection of the rash through the review date, and the resident's rash will heal by review date. Interventions include but not limited to: Give anti-pruritic medication as ordered by MD, monitor skin rashes for increased spread or signs of infection, and seek medical attention if skin becomes bloody or infected.R10's Physician's Orders, dated 04/03/25, documented Free of signs and symptoms of communicable diseases.R10's Physician's Orders, dated 07/01/25, documented Skin Checks-Perform upon admission and weekly thereafter, every evening shift every Thursday for facility protocol complete skin assessment under assessment tab. R10's Physician's Orders, dated 08/07/25, documented Benadryl Allergy oral capsule give 12.5 milligrams (mg) by mouth every 8 hours as needed for itching, hives.R10's Physician's Orders, dated 08/08/25, documented Silicone Cream to back of both legs BID every day and evening shift for dry areas.R10's Physician's Orders, dated 09/21/25, documented Clobetasol Propionate Cream 0.05% apply to affected areas topically every day and evening shift for skin.R10's Physician's Orders, dated 09/24/25 at 5:16 PM, documented Elimite External Cream 5 % (Permethrin) Apply to whole body neck to toes topically at bedtime for skin care until 09/25/2025 1:59 PM and remove per schedule.R10's Facility Nursing Home CNA shower sheet, for August 2025 and September 2025 were reviewed and documented the following skin issues:On 08/04/25, Rash to back of right lower leg.On 08/21/25, Rash to back of both lower extremities. Comments: Cream to legs.On 09/01/25, Rash to back of bilateral upper legs.On 09/11/25, Rash to right side, abdomen, and back areas.On 09/15/25, Scratches to right arm, both lower legs, and neck.On 09/18/25, documented treatment applied.On 09/25/25, Rash to upper chest, right abdomen, upper back, and left buttock. R10's Skin Checks, for August 2025 and September 2025 were reviewed and documented the following skin issues:On 08/07/25 at 4:33 PM, Skin issues: Needs review rash to left lateral calf and right lateral calf. They were in-house acquired, and the onset date is unknown. On 08/14/25 at 9:24 PM, There were no documented skin issues noted.On 08/14/25 at 4:33 AM, Skin issues: New issue rash noted to the left lateral calf and the right lateral calf. It was in-house acquired, and the onset date is unknown.On 09/12/25 at 4:37 PM, Skin issues: Reviewed Rash to left lateral calf and right lateral calf with an onset date of unknown. New skin issues of a rash to R10's Rt. outer wrist.On 09/25/25 at 4:52 PM, Skin issues: Evaluated rash to R10's left lateral calf and right lateral calf done showing improvement. R10's Progress Notes, were reviewed and documented the following:On 09/12/25 at 4:37 PM, documented Skin issue #001 Left lateral calf has a rash and #002 Right lateral calf has a rash. It is unknow how long it (rash) has been present.On 09/16/25 at 1:46 PM, documented Late Entry Note Text: Spoke with NP for local wound management regarding areas on multiple patients. NP suggested Medrol dose pack and Clobetasol 0.5% mixed with Cetaphil lotion BID. Suggestion sent to MD for orders. On 09/18/25 at 9:53 PM, documented Skin check showed R10 had a new skin issue, rash to right outer wrist. On 09/25/25 at 10:31 AM, documented Resident had a skin check done on 09-24 due to a small outbreak of scabies in the facility. Resident does have a small rash and will be treated, and all lines will be washed, family was notified and is fine with the treatment.On 09/25/25 at 4:52 PM, documented Rash to R10's left, and right lateral calf is showing improvement. On 09/30/25 at 1:25 PM, R10 said she got the rash about six weeks ago or so. She said she had it on both of her sides, stomach, and the back of her legs. R10 stated they had the NP (V11) from the local wound management come in and look at her rash and V11 said didn't know what kind of rash R10 had but said it looked like all the other rashes in the building. R10 said they didn't do any kind of skin scraping to see what kind of rash she had but they treated her last Thursday with a special cream, and they put it on from her hairline down to her feet. R10 said the itching stopped after that until just recently and it started itching again. R10 said the worst the itching has been on a scale of 0-10 with 10 being the worst has been a 7 and that was about two or three weeks into the rash. R10 stated more and more people on the east side was getting the rash. R10 said in the beginning they didn't really get a treatment for the rash they were just putting some silicone cream on it, and they ordered her Benadryl but she would only use it at night because it made her sleep. R10 said someone came around today and talked with her and she told them about the itching again and they were going to see if she could get another treatment with the special cream.On 09/30/25 at 1:25 PM, R10 has a raised red area on her right side going around to her back and on her abdomen. The facility's Infection Control Log for the months of August 2025 and September 2025 were reviewed and there was no documentation R1's, R2's, R6's, R7's, and R10's rash was being monitored or tracked. On 09/30/25 at 12:20 PM, V9 Assistant Director of Nursing (ADON)/Infection Control Preventionist (ICP)/Wound Nurse brought this surveyor a sheet of paper labeled Rash timeline it documented the following: First Rash EE Hall- R6 08/09/25 provider notified, and cream ordered.EE Hall- R7 08/18/25 cream ordered 08/18/25.NE Hall- R10 Benadryl ordered 08/23/25 and cream on the 25th. NE Hall- R11 cream ordered Medrol pack.EE Hall- R2 09/11/25 cream ordered.EE Hall- R12 09/18/25 cream ordered 09/19/25.EE Hall- R13 09/19/25 Benadryl ordered 09/23/25 and Medrol pack.SE Hall- R1 09/24/25 during sweep.On 09/29/25 at 1:42 PM, V5, Licensed Practical Nurse (LPN) stated they have had a few residents who had a rash, and they did the scraping and then the facility treated them for scabies. V5 said they were seen by V7, NP. V5 said they then treated everyone on the wing for them.On 09/30/25 at 8:01 AM, V9, ADON/ICP/Wound Nurse stated R5 was the first one to get the rash. She said at first, they didn't know what it was. They sent R5 to the dermatologist multiple times and they said it was dermatitis. V9 said other residents started to get rashes and none of the rashes looked alike so they had V11, Wound NP look at the rash and she ordered different creams and stuff. V9 said she heard staff had rashes and a few of the residents also. She said V10, CNA told her she had the rash since June or July, but she said another nurse told her V10 said it was since May. V9 said V10 was covered with the rash. She said V11 got V10 into a friend of hers who is a dermatologist and they did a scraping, and it was positive for scabies. V9 said when they found out V10 had scabies they treated the whole building for it and then the ones who had the rash will get a second treatment tomorrow (10/01/25). V9 was asked if she had any tracking/trending of when all of this started, she said not yet but she has been working on it because she knew this was going to happen.On 09/30/25 at 8:53 AM, V10, CNA said back in June she had noticed a rash on her stomach, and she said she didn't think much of it. She thought it was a heat rash because she had gotten a rash like that the summer before, and it went away. V10 said then in late July or early August she noticed the rash had spread to her chest, arms, and thighs. V10 said she didn't report to the office when she had first noticed her rash, but she did report about some of the residents having a rash. V10 said her and some of the other workers talked amongst themselves about them having a rash. V10 said they would all report it and put it on the shower sheets when they noticed any resident who had a rash. V10 said she thinks they contacted a doctor, and they ordered some type of cream. She said she isn't aware of them doing any kind of scraping on any of the residents at that time. V10 said they did not put any of the residents on any type of isolation or anything like that. V10 said V11, NP got her into a Dermatologist that was her friend, and they did a scraping, and it was positive for scabies. She said there were residents who had a rash before she developed the rash on her stomach. She said she doesn't have any kids at home they are all grown and no grandchildren. V11 said she comes to work and goes home and doesn't do much of anything else. She said it's just her and her husband at home and he still doesn't have any type of rash.09/30/25 at 10:24 AM, Follow up interview with V10, CNA. V10 said she remembers reporting R2, R5, R6, and R7, all had rashes. V10 stated she went to the doctor on 09/24/25 and can't return to work until 10/02/25. She said they are making her stay off for a week. She said while she was still at work, they did not put anyone in isolation but after that she doesn't know what they did.On 09/30/25 at 10:55 AM, V15, CNA said the staff have been telling administration for months that some of the residents have scabies, but they just tell the staff that's not what it is. She said they were trying to tell everyone it was from the laundry soap, but they all knew it wasn't. V15 said she isn't aware any scrapings being done on any of the residents. V15 said she feels like the staff got this from the residents and she doesn't think any of the staff brought it in. V15 said she knows she pointed it out to nurses on the resident's shower day and that was a couple of months ago. V15 said prior to the treatment no one was placed on any type of isolation. On 09/30/25 at 11:10 AM, V16, Regional Nurse Consultant stated she doesn't believe any of the residents had a skin scraping done. She said she knows they treated everyone out of abundance of caution they just treated everyone.The facility's Infection Prevention and Control Program, reviewed date of 9/5/25, documented Purpose To comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. It further documented Guidelines 6. The program provides for the recording of each suspected infection and surveillance activities as they relate to individual resident infections. A log is maintained o suspected and actual infections on a day-to-day basis. It also documented 19. Communicable disease outbreaks and infections that meet criteria for reporting will be reported to the Local and State Health Department. Investigation and/or outbreak line listing report will be completed as recommended.A document titled Scabies, dated 07/28/22 and found at Scabies - Symptoms and causes - Mayo Clinic documented Scabies is an itchy rash caused by a tiny burrowing mite called Sarcoptes scabiei. In the area where the mite burrows intense itching usually occurs and the need to scratch may be stronger at night. Scabies is contagious and can be spread quickly through close person-to-person contact in a family, school, or even nursing home. Symptoms of scabies include itching, often worse at night, and thin, wavy tunnels made up of tiny blisters or bumps on the skin.The Center for Disease Control (CD) information, dated 12/18/2023, documented Public Health Strategies for Scabies Outbreaks in Institutional Settings has a few key points. Scabies outbreaks have occurred in patients, visitors, and staff in institutional settings. When the characteristic symptoms of itching and rash are absent, it is easy to misdiagnose scabies, which can lead to outbreaks and often scabies is not recognized until it begins to appear among staff. Scabies can spread easily under crowded conditions where close body and skin contact is frequent and scabies outbreaks more commonly occur in the following settings such as nursing homes, extended care facilities, and childcare facilities. Early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks. Institutions should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies, even if characteristic signs or symptoms of scabies are absent (e.g. no itching). When there is concern for scabies in a person, skin scrapings should be obtained and examined carefully by a person who is trained and experienced in identifying scabies mites. Appropriate isolation and infection control practices (e.g., gloves, gowns, avoidance of direct skin-to-skin contact, etc.) should be used when providing hands-on care to patients/residents who might have scabies. Epidemiologic and clinical information about patients/residents with confirmed and suspected scabies should be collected and used for systematic review to facilitate early identification of and response to potential outbreaks.The facility should have an active program for early detection of infested patients/residents and staff. Maintain a high index of suspicion that scabies may be the cause of undiagnosed skin rash; evaluate and confirm suspected cases by obtaining skin scrapings. If there are multiple cases, notify the local health department of the outbreak; determine if there is evidence of an increase in scabies cases in the community; notify other institutions to or from which infected or exposed patients/residents may have transferred.Consult with an experienced dermatologist for assistance in differentiating between skin rashes and scabies. Ensure a trained and experienced staff member can obtain and examine skin scrapings to identify scabies mites.The facility should maintain records with patient/resident name, age, sex, room number, roommate(s) name(s), skin scraping status and result(s), and name(s) of all staff who provided hands-on care to the patient/resident before implementation of infection control measures: symptoms can take up to 2 months to appear in exposed persons and staff.MedRxiv.org document Impact of Scabies on Quality of Life and recent advances in management: A systematic Review, posted 11/26/2024, documented Scabies remains a significant global health issue, particularly in resource-limited settings. Despite its prevalence and impact on individuals and communities, scabies often receive inadequate attention in healthcare settings and research agendas. Scabies affects individuals of all ages and socioeconomic backgrounds, with a higher prevalence observed in overcrowded areas. The burden of scabies extends beyond physical discomfort, impacting quality of life, mental health, and economic productivity. Thus, it is imperative to diagnose scabies early and initiate treatment as soon as possible. The facility midnight census report 09/28/2025, dated 09/29/25 at 11:50 AM, documented there were 69 residents currently residing in the facility.

Based on interview and record review, the facility failed to prescribe physician ordered medications upon admission for 2 (R1 and R3) of 3 residents reviewed for pharmacy services in a sample of 3. Findings include: 1. R1's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnosis including anxiety disorder, major depressive disorder, bipolar disorder and panic disorder. R1 was covered by Med A benefits. R1's Hospital Discharge Paperwork, dated 8/7/2025, documents continue these medications which included Austedo XR 24 milligrams (mg) take 48 mg by mouth daily for treatment of depression and Vraylar 3 mg 1 capsule by mouth daily for treatment of depression. R1's Physician's Summary Report, dated 8/7/2025 documented do not send on Austedo XR 24 milligrams (mg) 2 tablets by mouth a day for treatment of depression and Vraylar 3 mg give 1 capsule by mouth once a day for treatment of depression. R1's Medication Administration Record (MAR), dated 8/2025, documents no Austedo 48 mg daily for treatment of depression or Vraylar 3 mg daily for treatment of depression was documented administered. 2. R3's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] and diagnosis including diabetes mellitus due to underlying condition with diabetic polyneuropathy. R1 was covered by Med A benefits. R3's Hospital After Visit Summary, dated 7/18/2025 documents Ozempic 1 mg into the skin once a week for treatment of diabetes was marked out and a handwritten note documented, Not while at facility. R3's MAR dated 8/2025, no documentation staff administered the physician prescribed medication Ozempic 1 mg into the skin once a week for treatment of diabetes. On 9/12/2025 at 2:00 PM V9, Pharmacist stated he receives resident's medication list upon admission to the facility, and he fills the prescriptions he can. When a medication is over the facility $200 threshold per medication he completes a high cost form which shows the current medication and the cost of it and then he documents an alternative lower cost medication and the cost of it then he emails the form to administration at the facility and they forward it to the resident's provider to see what they want to do which is either order the high price medication or chose to prescribe the low cost medication. When he receives a resident's medication list and staff document do not send or not while at facility he doesn't fill or send those medications and doesn't complete a high cost form because staff are communicating not to send the medication and if in the future the facility requests those medications marked that and if they are high cost medications, he would then send the facility the high cost form with an alternative low cost so the resident's provider can approve either medication. V9 stated R3's hospital discharge medication list dated 8/17/2025 was sent to him to fill the medications and the medication Ozempic 1 mg to treat diabetes was documented not while at facility. V9 stated R3 was prescribed no other medication to treat diabetes while she resided at the facility. V9 stated R1's POS dated 8/7/2025 was sent to the pharmacy with handwritten documentation do not send on the medications Austdro 24 mg take 48 mg by mouth daily for depression and Vraylar 3 mg by mouth daily for depression. V9 stated he didn't know what staff documented not to send the medications, but he didn't question it. On 9/12/2025 at 2:25 PM V11, Pharmacy [NAME] Director stated the facility has a $200 threshold for each medication the facility fills, if the medications cost more than that threshold the pharmacy staff are instructed to complete a high cost medication form and documents a lower cost alternative medication on the form and email it to the facility then the provider decides what medication they want to prescribe and the facility sends it back to the pharmacy and the medication is filled. V11 stated R3's Ozempic 1 mg medication to treat diabetes was an injectable and they are always expensive, V11 stated Ozempic is a high-cost medication and cost around $1500.00 a month. V11 stated R1's medication Austrdro 48 mg daily for depression is very expensive and costs $6,000.00 for a 14-day supply and Vraylar 3 mg for depression is also expensive as it cost $700.00 for a 14-day supply. V11 stated these medications for R1 and R3 were not filled from the pharmacy because staff handwrote a note on the medication list that stated, do not send or not while at facility. V11 stated she was the billing director, and she didn't know who documented not to send the medication on the resident's medication lists that were sent to the pharmacy. On 9/16/2025 at 10:00 AM V23, Nurse Practitioner stated she wasn't aware the facility wrote on R1's and R3's admission medication list that was sent to pharmacy with a handwritten note not to fill medications. V23 stated the facility staff don't have the authority to not fill physician prescribed medications and it most definitely should not be occurring. V23 stated R1 has multiple mental health diagnoses including major depressive disorder and abruptly stopping any of those medications including Austedo and Vraylar to treat her major depressive disorder could cause her to downward spiral into a deep depression and ultimately, she could be so depressed she commits suicide. V23 stated R3 had a diagnosis of diabetes and that's what the injectable medication, Ozempic 1 mg was prescribed to treat. V23 stated R3 wasn't prescribed any other medication to treat diabetes while at the facility and she wasn't aware facility staff put a handwritten note on R3's medication list sent to the pharmacy documented, Not while at the facility. V23 stated she should have known staff were making that decision to not treat R3's diabetes because she would have at least ordered staff to check R3's blood sugar a few times a day and if it was high she would've prescribed sliding scale insulin. V23 stated she knows why the facility isn't filling all the resident's medications, it's because residents on Med A have the facility is responsible for paying for their medications and the facility is always harping her to prescribe lower cost medications and she can't sometimes. On 9/17/2025 at 11:00 AM V1 Administrator, V3 Assistant Director of Nurses and V24 Regional Nurse Consultant stated they were not aware of facility staff writing on resident medication lists that are sent to pharmacy with handwritten notes documenting do not send or not while at the facility. V1 stated pharmacy staff should've questioned that because they know facility staff do not have the authority to document a note like that and not to send the medication or notify her or V2, Interim Director of Nurse of what's going on so they can look into it. V1 stated the facility has a $200 per medication threshold and the pharmacy knows that so when there is a high cost medication the pharmacy emails her a high cost form that documents the current prescribed medication and an alternative lower cost medication and she forwards these forms to the provider, the provider ultimately decides what medication is to be prescribed and the facility will pay for it if the resident is on Med A. No staff stated they were aware of staff documenting handwritten notes on residents' medications lists and sending it to the pharmacy. On 9/18/2025 at 11:44 AM V1, Administrator responded to an email and stated, We do not have a formal policy, we request pharmacy provides alternatives and recommendations regarding medications over $200 that must still be approved by the resident physician. No one goes without medications, if there is no alternative to a high cost medication or the physician declines an alternative/generic, the medication is still provided to the resident.An Undated Physician's Orders Entering and Processing Policy, documents to provide general guidelines when receiving, entering, and confirming physician or prescriber's orders. (a prescriber is noted as physician, nurse practitioner, and a physician's assistant.) Fax or call the orders to the appropriate pharmacy as needed. If pharmacy is integrated with EHR (Electronic Health Record), orders will be automatically transmitted. Notify the resident's physician (if not the prescribing physician), for verification if applicable.

Based on interview and record review the facility failed to follow the privacy policy for 1 (R5) of 3 residents reviewed for privacy in the sample of 3.Findings include: R5's Undated Face Sheet documents he was initially admitted to the facility on [DATE]. R5's Quarterly Minimum Data Set (MDS) dated [DATE] documents he is alert. On 9-17-2025 10:35 AM V10, Former LPN stated she received a text message on her personal cell phone on 9/6/2025 which included V1 Administrator, V3 ADON and V24 RNC and it had R5's first and last name and documented detailed health information regarding R5 which she felt was not appropriate to communicate via cell phone text message because it is not secure or encrypted and it's a HIPPA/privacy violation. V10 stated the text message was initiated by V3. V10 stated she responded to the text message immediately, Please delete my name and do not message me again. Probably shouldn't put HIPAA information with an employee you banned from your facility. An undated text message sent at 12:21 PM documents V3, ADON initiated the text message which included V1, V3, V10 and V24. The text message read resident name (R5) he pulled his midline out this morning. He did this twice with PICC when we tried to treat previously. A urine was collected because he was increasingly confused and urine was very mocousy and odorous. He has a midline that we were treating him for EBSL in his urine but pulled it out this morning. He has about 10 more doses to go before completion of therapy. We have tried wrapping it in coban and putting long sleeves on him but he is confused and doesn't remember one day from the next. I know we ow have to get approval for reinsertion. I feel like if we don't treat him then he is going to go septic and end up in the hospital or worse. What do you suggest? Thank you.Three undated screenshots of the text messages were submitted and reviewed for evidence which showed the above information.R5's Nursing Notes dated September 2025, no documentation of staff sending a text message with his medical information in it. On 9/12/2025 at 10:15 AM V1, Administrator stated they don't text message resident names or medical information because that would be a privacy/HIPPA issue.On 9/17/2025 at 10:50 AM V24, Regional Nurse Consultant stated she received a text message recently (date unknown) that had a resident's first and last name and medical information in it. V24 stated the text message was from V3, ADON and she knew immediately it was an issue because text messages are not secure for resident medical information, and it was a HIPPA/privacy issue. On 9/17/2025 at 11:00 AM V1, Administrator stated V3 the ADON sent her a text message on her cell on 9/6/2025, the text message included a resident's first and last name and detailed medical information. V1 stated she inserviced all staff, including V3 regarding not text messaging resident's names or medical information because text messages or not encrypted or secure and it is a HIPPA/privacy issue. V1 stated she expected all staff to follow the facility policies and procedures, including the facility's privacy policy. On 9/17/2025 at 11:05 AM V3, ADON confirmed the phone number was hers that initiated the text message and stated she recalled the resident's name was R5 and she meant to text message the R5's name and medical information to V1, and V25, [NAME] President of Operations and V24, RNC but she accidently put the wrong person in the group which included V10, Former LPN, after V10 replied with no to message her anymore she realized she text messaged the wrong person and stopped any further text messages regarding R5 and his medical care. V3 stated sending the text message to V10 was an accident and she knew better than to text message a resident's name and medical information but it was a weekend and she needed guidance on how to proceed with caring for R5. V3 stated V1 inserviced her on 9/8/2025 regarding not text messaging resident's names and medical information because it's not secure or encrypted and stated she won't text message resident information again. The Facility's HIPPA Policy and Procedure, dated 6/1/2025, documents this policy applies to all employees with access to personal health information (PHI.) This includes all administrative, clinical and support staff. Definition: PHI: any information recorded in any form, that relates to health, provision of health care that can be linked to an individual. Staff members will receive training on HIPAA policies and procedures, with additional training provided as rules and regulations evolve. This training includes but is not limited to privacy practices, security measures and breach notification procedures. Violations of this policy may result in disciplinary action.

Based on observation, interview, and record review, the facility failed to ensure resident's rooms are maintained at comfortable temperature for 2 out of 3 residents (R1 and R2) reviewed for homelike and comfortable environment in a sample of 4. Findings Include: 1. R2's Face Sheet, print date of 07/07/25, documented he has diagnoses of but not limited to Chronic obstructive pulmonary disease, obstructive sleep apnea, and Ischemic Cardiomyopathy. R2's Minimum Data Set (MDS), dated [DATE], documented he is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and he is dependent on staff or requires substantial/maximal assistance with his activities of daily living (ADLs). On 07/02/25 at 1:40 PM, R2 was lying in bed with just a sheet on the lower half of his body. He did not have on any clothing on the upper half of his body. He had a small osculating fan sitting on his over the bed table blowing directly on him. The room was warm and stuffy. R2's room did not have any air conditioning vents in it and there was no individual air unit of any kind in his room. On 07/02/25 at 1:40 PM, R2 said they have been having problems with the air in the facility for the last four or five days. He said it has been getting hot in his room and the only air vents are out in the hallway, and he doesn't have any in his room. R2 said they have been checking the temperatures in the hallway, but they haven't checked the temperature in his room. R2 said he has heart problems and doesn't tolerate the heat very well. He said when the Certified Nursing Assistants (CNAs) come in and do patient care and they shut the door it gets even hotter. He said the CNAs are sweating and he even starts to sweat. He said sometimes it feels like it is over 100 degrees in there. On 07/02/25 at 2:50 PM, R2 stated they came in and offer to move him to another room after this surveyor had left the room. He said they had never offered before that. He said they also came in and temped his room and they had never done that before either. R2 said they didn't tell him what the temperature was after they took it. This surveyor took a calibrated thermometer into R2's room and asked if I could test and see how hot it was in his room, and he agreed. This surveyor laid the thermometer on the over the bed table with nothing touching it. This surveyor stayed in the room and talked with R2 and after five minutes of lying on the table the thermometer read 79 degrees. This surveyor continued to speak with R2 and after another five minutes the thermometer was checked again and it still read at 79 degrees. This surveyor was just standing in the room with R2 and had sweat on my forehead. R2 said the room even gets hotter than it was now especially between 10:00 AM and 11:00 AM when the sun is directly over his part of the building. 2. R1's Face Sheet, print date of 07/07/25, documented R1 has diagnoses of but not limited to Chronic Embolism and Thrombosis of unspecified vein, urinary tract infection, and disorder of the bone. R1's MDS, dated [DATE], documented R1 is cognitively intact with a BIMS of 15 out of 15 and she requires substantial/maximal assistance to dependent on staff for her ADLs. On 07/02/25 at 1:30 PM, R1 said they have been having an issue with the air conditioner. She said the first night it was out she sit up for four hours because it was so hot, and she was unable to sleep. She said finally one of the nurses got her a fan and she was able to get some rest. She said sometimes the heat in the room gets bad and it is miserable in there. R1 said they are waiting on a part for the air conditioner. On 07/02/25 at 1:30 PM, V4, CNA said it has been hot on the hallway and the air hasn't been working for a few days. She said she knows they have been trying to get someone to come in and look at it. V4 said they gave the residents box fans to help with the heat but trying to work in the heat was miserable. On 07/02/25 at 1:50 PM, V5, Licensed Practical Nurse (LPN) said it was the weekend before this last weekend is when the air went out. She said she knows because she was working that weekend. V5 said she call management and told them what was going on, but they didn't do anything. She said they told them to close the blinds and to turn off the lights. V5 said all the residents were miserable. V5 said they didn't offer to move any of the residents that she is aware of. She said the nurse's stations doesn't have any air conditioning vents in the hallways are the only vents there are the residents don't have vents in their rooms. V5 said they had their maintenance guy look at it and the regional maintenance director came in and said it's hotter than Satan's Breath in here. On 07/02/25 at 1:50 PM, The east wing nurse's station was warm and muggy. On 07/02/25 at 2:15 PM, V7, CNA said they have been having an issue with the air not working right for a couple of weeks now. She said it has been miserable in the building for the residents and the workers especially during that hot spell they had not too long ago. On 07/07/25 at 9:40 AM, Room temperature (temps) log was reviewed and documented temps were taken on 07/03/25, 07/04/25, 07/05/25, 07/06/25, and 07/07/25 there were no room temps documented prior to 07/03/25. The temperatures were as follows: R2's room temperatures: 07/03/25 at 09:09 AM room was 76 degrees and at 12:42 PM room was 79 degrees. 07/04/25 at 10:07 AM room was 75 degrees. 07/05/25 at 11:41 AM room was 76 degrees. 07/06/25 at 08:23 AM room was 76 degrees. 07/07/25 at 08:15 AM room was 75 degrees. R1's room temperatures: 07/03/25 at 09:09 AM room was 76 degrees and at 12:41 PM room was 78 degrees. 07/04/25 at 10:07 AM room was 75 degrees. 07/05/25 at 11:41 AM room was 77 degrees. 07/06/25 at 08:22 AM room was 74 degrees. 07/07/25 at 08:15 AM room was 74.9 degrees. Facility grievance, dated 06/24/25, documented residents were wanting air conditioners in their rooms. The facility's policy Extreme Temperatures, with a review date of 06/30/25, documented Purpose To assure the comfort and safety of residents and to prevent heat stress of residents during periods of extreme heat.

Based on interview and record review the facility failed to properly transfer and use appropriate assistive devices for transfers for 1 of 3 (R2) resident investigated for falls. This failure resulted in R2 sustaining a left knee periprosthetic fracture of the tibial component. Findings include: R2's EMR (Electronic Medical Record) undated documents that the resident was readmitted to the facility on [DATE]. R2's EMR dated 2/9/22 documents a diagnosis of other abnormalities of gait and mobility. R2's EMR dated 11/5/24 documents a diagnosis of difficulty in walking, not elsewhere classified. R2's EMR dated 8/14/24 documents a diagnosis of unspecified fracture of left fibula, subsequent encounter for closed fracture with routine healing. R2's MDS (Minimum Data Set) dated 7/26/24 documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS documents that the resident was independent for roll left and right. The MDS documents that the resident required substantial/maximal assistance for sit to lying. The MDS documents that the resident required partial/moderate assistance for lying to sitting on side of bed. The MDS documents that the resident was dependent for sit to stand, chair/bed to chair transfer, and toilet transfer. R2's Care Plan dated 4/30/25 documents (R2) is at risk for falls. She had a L knee replacement and is unstable ambulating and transferring herself. R2's Care Plan dated 4/30 /25 documents The resident has had an actual fall with serious injury. R2's Nursing Note dated 8/3/24 at 1:15 PM documents cna (Certified Nursing Assistant) came to this nurse to let this nurse know that resident was lowered to the ground. CNA stated resident stated that her left leg gave out and then she was lowered her to the ground. States her left knee hurts. ROM (Range of Motion) WNL (Within Normal Limits). Transferred back to wheelchair. V/S (Vital Signs)-97.2-102-22-102/64-spo2 (oxygen saturation)-97%. On call NP (Nurse Practitioner)-for (V6) notified. No number to contact for her husband. Will monitor. Tylenol given for pain. R2's Nursing Note dated 8/14/24 at 5:30 AM documents X-ray results of tib/fib back- results showed fracture involving distal fibula. Management notified. X ray results were also taken on 8-4 of femur and tib/fib, results were negative on 8-4. R2's NP Progress Note dated 10/8/24 documents Patient is being seen today for a skilled nursing home visit. She was recently admitted to the facility following hospitalization for UTI, debility and septic joint. She underwent arthrocentesis with orthopedic surgery and IV antibiotics during her hospital stay. She then fell in the facility and now has a left knee periprosthetic fracture of the tibial component. She is A&O x 3 and can verbalize her needs. She was seen today in-her room while sitting in her wheelchair. She has been released from her immobilizer and is WBAT to her LLE. Although, she now reports she reinjured her right knee by twisting while in the wheelchair. She states she doesn't have any pain but is unable to stand on it and now it is red again and swollen. She is utilizing the wheelchair for ambulation. Staff has no acute concerns at this time. On 5/20/25 at 9:15 AM, V4, PTA (Physical Therapy Assistant) stated that (R2) started off as (Mechanical) lift for transfers and then transitioned to a sit-to-stand for transfer when she got here in July of 2024. On 5/20/25 at 10:48 AM, V5, CNA stated that she was helping (R2) to the bathroom on 8/3/24. She stated that (R2) was a one assist with a gait belt. She stated that she was assisting (R2) to the bathroom. She stated that about the time they made to the doorway of the bathroom, that (R2's) leg gave out and was she assisted to the floor. She stated that they used a (Mechanical) lift to get her up off the floor. On 5/20/25 at 10:50 AM, V4, PTA stated that on the day of (R2's) fall, she was supposed to be transferred using a sit-to-stand device. On 5/20/25 at 12:32 PM, V4, PTA stated that the CNA transferring (R2) improperly lead to her having a fracture leg. She stated that the therapy was working with contact guard assist with (R2) but she was not released yet. Facility's policy undated documents It is policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. 1. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. 2. The resident's mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations.

Based on observation, interview and record review the facility failed to monitor and treat a suspected deep tissue injury (SDTI) for 1 of 4 (R7) reviewed for pressure ulcers in the sample of 25. This failure resulted in R7 documented as having an SDTI reported as first being observed on 8/20/2024 to the right toe(s) with no skin monitoring or treatments implemented until 10/8/2024. At that time gangrene was present, requiring hospitalization with right second toe amputation on 10/19/2024. Subsequently R7 required additional amputation to her right lower extremity, above the right knee on 11/30/2024. The Immediate Jeopardy began on 8/20/2024 when staff documented a skin area of concern on R7's right toe(s.) No assessment or treatment was documented on her right toe(s) until 10/8/2025 when she was hospitalized , diagnosed with gangrene, osteomyelitis and had her right 2nd toe was amputated on 10/19/2024. Due to worsening infection R7 was re-hospitalized and additional amputation to her right lower extremity, above the right knee on 11/30/2024. On 1/30/2025 at 2:35 PM V1, Administrator and V2, DON were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 1/31/2025, but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R7's Admission Record dated 1/29/25 documents R7's initial admitted to the facility as 5/9/17. Diagnoses listed on this same document include, but are not limited to: Cerebral Infarction due to embolism of unspecified cerebral artery, Chronic obstructive pulmonary disease, type II Diabetes Mellitus, Morbid obesity, and Osteomyelitis. R7's Braden Scale for Predicting Pressure Ulcer Risk dated 2/24/2021 documents she is a risk for pressure ulcers. No further updated Braden Scales were documented. R7's Minimum Data Set (MDS), dated [DATE] documents in section C, Cognitive Patterns that R7 has a Brief Interview for Mental Status (BIMS) score of 14, cognitively intact. This resident is at risk of developing pressure ulcers. No unhealed pressure ulcers. R7's Physician's Order Sheet (POS) dated 8/2024 documents an order dated 12/20/2022 weekly skin checks on shower days Tuesdays and Fridays. R7's Skin Observation Tool dated, 6/19/2024 documents R7 had an area on her left elbow. No other skin areas documented. R7's Medical Record dated 6/20/2024 through 8/20/2024 no weekly skin assessments documented. R7's Dialysis Foot Skin Assessment, dated 7/24/2024 documents no areas of concern on feet. R7's Minimum Data Set (MDS), dated [DATE] documents resident alert, no pressure ulcers, at risk of pressure ulcers. R7's Nurse Practitioner Progress Note, dated 8/20/2024 documents skin is warm and dry, with no rashes, good skin turgor, no suspicious skin lesions. R7's CNA (Certified Nurse Aide) Shower Sheet, dated 8/1/2024 through 8/19/2024 no skin areas of concern documented. 8/20/2024, 8/23/2024, 8/27/2024 and 8/30/2024 documents right foot/toe lateral and medial bruising and left heel soft spot. A nurse signed each page of the shower sheets. Comments documented: sent to V3, ADON, wound nurse. R7's Nurse Nursing Note, dated 8/21/2024 at 9:48 AM, documents dialysis nurse called to report area to resident left heel and right great toe. Wound nurse informed. R7's Physician's Order Sheet (POS) dated 8/2024 documents left heel treatment start date 8/26/2024 left heel cleanse with normal saline or wound cleanser, paint with betadine, leave OTA (open to air) may cover if open and draining daily and PRN (when necessary) every day shift for wound care. No physician's order for treatment to resident's right toe. R7's Care Plan dated 8/26/2024 documents R7 has potential impairment to skin integrity r/t (related to) fragile skin, edema and dry areas. Treatments ongoing as per MD (physician) orders. 8/26/2024 left heal DTI, wound company nurse practitioner treatment, treatment in place. Goal: resident will maintain or develop clean and intact skin by the review date. Interventions: float heels while in bed and encourage resident to elevate legs as often as possible, air mattress on bed, encourage side to side positioning with turn and reposition every 2 hours, follow facility protocols for treatment of injury, keep skin clean and dry, use lotion on dry skin. Offload heels by applying heel protectors when in bed. Educate to leave heel boots on, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R7's Treatment Administration Record (TAR) dated 8/2024 staff documents 8/26/2024 through 8/31/2024 left heel treatment was administered. No documentation left heel treatments 8/21/2024 through 8/25/2024. No documentation of right toe wound being treatment. R7's Dialysis Progress Note dated, 8/21/2024 at 10:50 AM documents pt (patient) c/o (complaint of) feet hurt. Upon inspection large, darkened area noted to left heel/bottom of foot area and right great toe/top of right foot noted to have large red/purple area. Facility nursing home nurse, Former Administrator notified of areas. She states she will pass information along to restorative nurse. R7's Wound - Weekly Observation Tool dated 8/21/2024, 8/28/2024, 9/4/2024, 9/10/2024, 9/17/2024, 9/24/2024, and 10/1/2024, documents dialysis reported an area to L (left) heel and R toe. L heel noted DTI (Deep Tissue Injury), order entered. The left heel first observation dated 8/21/2024 documents DTI measured 4.2 centimeters (CM) x 3.6 cm. No documentation of area on right toe documented. R7's POS, dated 9/2024, documents an order dated 9/4/024 wound company to evaluate and treat left heel wound. No physician's order to treat the right toe. R7's CNA Shower Sheet, dated 9/24/2024 documents dressing on (R7s) right foot. No nurse signature documented on shower sheet, or physicians order for a dressing documented. R7's Wound - Weekly Observation Tool dated 10/8/2024 documents first observation SDTI on R (right) 1-2 toe crease, measured 0.4 cm x 2.8 cm 100% slough with red peri wound tissue. R7's TAR dated 10/9/2024 through 10/14/2024, documents a physician's order cleanse areas between right great toe and second toe with normal saline or wound cleanser. Apply betadine moistened gauze and cover with dry dressing every day shift for wound management. R7's Nurse Progress Note, dated 10/15/2024 at 1:46 PM documents Weekly Wound Assessment- wound company nurse practitioner V16 seen resident this morning. L heel measures at 1.9 cm x 2.0 cm. Healing well. Continue with betadine paint and air dry. R 2nd and 3rd toe new area measures at 2.0 cm x 6.65 cm x 1.0 cm. Wound Nurse Practitioner explained to resident and family member regarding the need to be sent out to hospital for further workup with vascular regarding the new wound. Resident has abundance of purulent drainage and pain at the site. Applied moist betadine gauze bandage. Resident is a diabetic and currently receiving dialysis. Resident agreed to go to local hospital to be seen vascular. Will f/u (follow up) in 1 week. R7's Hospital Discharge Paperwork dated 10/21/2024, documents was hospitalized [DATE] through 10/21/2024 documents hospitalization chief complaint worsening right toe wound. Resident stated wound has been present for a month has been present for 1 month but has been worsening and is painful. Right second toe dry gangrene and osteomyelitis. Acute on chronic right second toe wound x 1 month. Status post amputation of right 2nd toe on 10/19/2024. MRI showed Osteomyelitis (bone infection) involving first and second phalanges (toes) as well as base of first digital phalanax (toe.) R7's POS dated 10/2024, documents an order dated 10/15/2024 send to local hospital for evaluation and treatment related to right toe wound. R7's POS dated 10/2024, documents an order dated 10/22/2024 right great inner toe apply betadine paint and let air dry daily and PRN every day shift for wound care. No treatments were documents as administered between 10/8/2024 and 10/15/2024. No physician's order to treat the resident right toe wound. R7's TAR dated 10/2024, staff documented treatment per physician's orders was completed 10/26/2024 through 10/31/2024. R7's Hospital Discharge paperwork dated 12/3/2024 documents she was admitted to the hospital with chief compliant status post right foot 2nd toe amputation due to wound was worse and had osteomyelitis in all toes on right foot at that time. An above the knee amputation was done on 11/30/2024 due to the worsening right foot wound. On 1/30/2025 at 10:00 AM, R7 was observedl lying in bed. She had an above the knee right leg amputation and her left foot was in a boot. R7 her feet hurt all the time and the pain started in 8/2024. R7 stated her right foot was a 6/10 on pain scale and 8/10 on her left foot. R7 stated at that time that if her right foot doesn't get any better that they are going to amputate it. On 1/30/2025 at 10:25 AM V10, LPN, and V3, ADON, provided wound care to R7 with no issues. R7's left 2nd toe and 5th toe darkened. Skin between all toes is dark. Left heel scabbed over and dark. Right leg above the knee stump was dry with no open areas. On 1/30/2024 at 10:20 AM V3, ADON stated each resident should have 2 shower sheets done per week and a licensed nurse should also be assessing each resident head to toe skin assessment and documentation should be in each resident's medical record. She stated she wasn't aware of R7's right toe wound on 8/20/2024 even though it's documented on the shower sheet that it was sent to her. She stated staff were documenting information in a phone communicate app at that time and she didn't see the message regarding the right toe. V3 confirmed she wasn't aware of any skin breakdown or issues with the resident's right toe until 10/8/2024, that was her first assessment of the resident's right toe and she documented her assessment in the resident's medical record. On 1/29/2025 at 8:45 AM V15, Dialysis Clinical Manager stated they check resident's feet at dialysis once a month. On 8/21/2024 the resident told dialysis staff that her feet hurt. Upon assessment of her feet she had a large dark area noted to left heel and right great/top of right foot noted to have large red/purple area. The facility was notified of the skin areas of concern. On 1/29/2025 at 12:30 PM, V2 Director of Nurses (DON) stated when residents are admitted to the facility on e of the standing orders is for the resident to have a weekly skin assessment. V2 expects nurses to assess and document weekly skin assessments in the resident's medical record. When a new skin area is identified as a concern, she expects the nurse to assess the area and document what it looks like and measurements, she also expects the nurse to notify the physician and get a treatment in place immediately. When two areas of skin concern are identified at the same time the nurse should assess and document both areas of skin concern in the resident's medical record. V2 stated she knows the wound nurse practitioner was seeing the resident for her left heel and right toe but wasn't sure when she initially assessed the resident's wounds. On 1/29/2025 at 12:38 PM V6, MDS/Care Plan Coordinator stated when a new skin concern is identified he expects the care plan to be updated immediately/within 24 hours. Residents are assessed quarterly for pressure ulcer risk assessment. On 1/29/2025 at 12:45 PM V3, Assistant Director of Nurses (ADON) stated the wound nurse practitioner started assessing the resident's wound on her left heel on 9/10/2024 and right toe 10/15/2024. She was made aware of the area on the resident's right toe on 10/15/2024, V3 stated she was so focused on treating the resident's left heel that she wasn't aware of the area of concern on her right foot. On 1/29/2025 at 12:55 PM V5, CNA Coordinator stated when staff document a 1 on resident's shower sheets it means bruising was observed and the nurse should go follow up on that documentation/finding. On 1/29/2025 at 2:15 PM V13, CNA recalled documenting on R7 on 8/20/2024 and stated she documented bruising on her right foot but it was of two darkened areas than bruising and her left heel was soft. V13 stated she told the nurse (name unknown) about the areas of concern and the nurse signed her shower sheet to prove she was aware of the areas. On 1/30/2025 at 11:00 AM V16, Certified Wound Nurse Practitioner stated the resident has a lot of comorbidities including end stage renal failure and diabetes. V16 stated despite these comorbidities, when a wound is observed by staff she expects staff to notify the nurse and the nurse should notify the primary care physician to obtain a wound treatment and to get the treatment in place as soon as possible. The nurse who initially assesses the new wound should the document color, size and presentation of the wound. The first time she assessed the resident's right foot was on 10/15/2024 and her 2nd toe was ischemic (reduced blood flow to specific tissue) and she notified the vascular physician at the local hospital and the resident was sent to the emergency room the same day. When she assessed the resident on 8/20/2024 she didn't do a full skin assessment, she only looks at concerns that the facility notifies her about it. She assessed the resident's left foot but wasn't notified of any concerns or issues regarding her right foot. V16 stated untreated wounds have the potential for serious harm or death due to infection. V16 stated she expected the facility to follow the pressure ulcer policy. On 1/30/2025 at 11:38 AM, V17, Licensed Practical Nurse (LPN) stated she recalled the resident having skin breakdown on her feet in 8/2024 but she couldn't recall what her feet looked like at that time and she recalled messaging the wound nurse (V3) regarding the skin breakdown and she usually documents a nurse progress note when she assesses new skin breakdown but she didn't know if she documented it or not. On 1/30/2025 at 1:08 PM, V3 ADON stated on 10/8/2024 she can only assume the wound on (R7's) foot was worse and staff notified her of it and she assessed and classified it as a SDTI and then on 10/15/2024 when the wound nurse practitioner assessed it was a lot worse and that's why she was sent to the emergency room for further evaluation and treatment. On 1/30/2025 at 1:35 PM, V17 LPN stated she knows for a fact that she reported (R7's) skin breakdown to V3 and this happens all the time that she and other staff including other nurses report to V3 concerns and issues and V3 always says I didn't know about that or no one told me about that. On 1/30/2025 at 2:20 PM V13, CNA reviewed the shower sheet, dated 9/24/2024 she recalled the resident had a dressing on her right foot but she didn't recall any details regarding the dressing. On 1/30/2025 at 2:25 PM V18, Nurse Practitioner stated when nursing staff identify a new skin concern/wound she expects a licensed nurse to assess the area and to notify her or the resident's primary care physician the same day, typically the facility will phone or fax what the wound looks like and measurements and what the wound looks like and document if there is a treatment in place already. V18 expects the facility staff to follow the facility pressure ulcer policy. V18 stated staff should be assessing (R7's) feet because she has diabetes and anything on the foot with diabetes can continue to progress into a wound. Wounds and infections have the potential to lead to death if not treated appropriately and in a timely manner. Review of the facility policy titled, Pressure Injury Prevention and Management dated 9/1/21 documented, The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. The same policy goes on to define avoidable as meaning, that the resident developed a pressure ulcer/injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Policy Explanation and Compliance Guidelines includes: 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .3. c. Licensed nurses will conduct a full body skin assessment on all resident upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. D. Assessments of pressure injuries will be performed by a licensed nurse, and documented in the medical record . The following mitigating actions are being put into place to prevent future wound development: 1. The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 1/30/25) Skin Assessments were conducted on all residents. No new wound concerns were identified. A medical records review was completed on all residents to ensure weekly skin assessments were completed and treatment recommendations/orders were in place. A care plan audit was conducted to ensure that all active wounds were on the Care Plan and that Care Plan is being followed. An audit was conducted to assure all treatments are in place. 2. The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 1/30/25) All facility policies and procedures related to skin care, wound care, and pressure injury prevention were reviewed and revised as needed. provided education to all licensed nurses on facility policies and procedures related to skin/wound care, as well as appropriate wound treatment measures, as well as Change of Condition Notifications. provided education to all licensed nurses on appropriate documentation which included transcription and entering of treatment orders on the physician's order sheet in the EHR and the resident's TAR. educated all nurse aides on preventative skin care. will conduct treatment record and nursing documentation audits during morning clinical meetings to ensure accurate and complete documentation of skin related treatments and preventative measures. For residents returning from the hospital, treatment recommendations/orders and wound care appointments will be transcribed and overseen monitor/audit the following: o Observation of treatments 2 times weekly x four weeks and weekly x two weeks o Preventative skin care 2 times weekly x four weeks and weekly x two weeks o Weekly skin assessments weekly x 6 weeks o Treatment recommendations and orders are being added and processed into the EHR and TAR 2 times weekly x four weeks and weekly x two weeks. All findings will be discussed in the Quality Assurance Meeting

Based on interview and record review the facility failed to insure the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. This failure has the possibility to affect all 77 residents residing in the facility. Findings include: Facility Assessment Tool undated documents under staff RN minimum of 12 hours per day. Facility's January 2025 Nursing Schedule documents that the facility did not have an RN (Registered Nurse) working on 01/01/25, 01/02/25, 01/04/25, 01/05/25, 01/15/25, 01/16/25, 01/17/25, 01/18/25, 01/19/25, and 01/24/25. On 01/29/25 at 12:50 PM, V2, DON (Director of Nursing) stated that in January, the facility did not have an RN working every day. She stated that the facility did hire a new RN that started January 22nd. On 01/31/25 at 9:58 AM, V1, Administrator supplied a paper that stated (Facility Name) staffs Nurses and CNAs to State and Federal requirements and resident needs. Resident Census and Conditions of Residents dated 01/28/25 documents a census of 77 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to provide adequate supervision, implement new care plan fall prevention/interventions, and assure current interventions were in place for 2 of 3 residents (R2 and R3) reviewed for falls in a sample of 3. This failure resulted in R2 having an unwitnessed fall and sustaining a fractured hip that required surgery to repair. Findings include: 1. R2's Admission Record, with admitted [DATE], documented R2 has diagnosis of but not limited to Dementia, osteoporosis, abnormalities of gait and mobility, and unilateral primary osteoarthritis, right knee. R2's Minimum Data Set (MDS), dated [DATE], documented R2 is severely cognitively impaired with a Brief Interview of Mental Status (BIMS) of 04 out of 15 and requires partial/moderate assistance with toileting hygiene, shower/bathe, dressing of upper half of body, bed mobility, substantial/maximal assistance with dressing of the lower half of body, putting on/taking off footwear, personal hygiene, and transfer. It further documents walking was not attempted due to medical condition or safety concerns. R2's Care Plan, with admitted [DATE], documented R2 had an actual fall with no injury on 09/12/24 and an unsteady gate. R2's goal is she will resume usual activities without further incident through the review date. Intervention is R2 will use a bed/chair alarm. R2's Admission Morse Fall Scale, dated 09/07/24, documented R2 had a score of 80 and was a high risk for falling. It further documented R2 had a history of falls, had more that one diagnoses on her chart, used ambulatory aides such as crutches, cane, or a walker, had a weak gait, and overestimates or forgets limits. The Morse Fall Scale ranges are as follows: High Risk 45 or higher, Moderate risk 25-44, and low risk 0-24. R2's Progress Notes, dated 9/12/2024 at 02:15 AM, documented Incident Note: This nurse was notified by CNA (Certified Nursing Assistant) that resident was found on the floor in the bathroom lying on her side. Nurse completed a physical and neurological assessment on resident. Resident alert, orientated per norm. Able to move all extremities freely with no response of pain or discomfort. Hand grasps equal and strong. No abrasions or abnormalities noted to head or body. Vitals taken - 98.1, 97, 165/90, 20, & 94% RA (room air). No s/s (signs/symptoms) of pain/discomfort noted. Resident assisted back to feet, then bed via CNAs and nurse. Weakness to BIL (bilateral) legs noted on walk over. Neuros initiated due to being unwitnessed. MD (doctor) and DON (Director of Nursing) notified. R2's Post Fall Morse Fall Scale, dated 09/12/24, documented R2 had a score of 95 and was a high risk. R2's Fall Investigation, dated 09/12/24 at 02:15 AM, was reviewed and documented Notes: Interdisciplinary Team (IDT): FALL: Resident attempted to take herself to the bathroom and fell . Resident has been having more difficulty walking. Short, shuffling steps. More difficulty standing up. Resident unable to say what happened at time of her fall. Range of Motion (ROM) within normal limits (WNL). No complaints of (c/o) pain or discomfort. Upon further review and discussion with IDT team, resident will be evaluated by therapy. Power of Attorney (POA) and MD updated. R2's Progress Notes, dated 10/3/2024 at 07:38 AM, documented Nursing Note: Resident was sitting in chair by nursing station, alarm sounded, CNA found resident on floor next to chair laying on left side. Resident was transferred back to chair via (Mechanical) lift. ROM (Range of Motion) in upper extremities wnl (within normal limits), no discomfort. Right lower ext (extremity) rom wnl, no signs of discomfort. left leg is at 90-degree bend, will not straighten. left hip rom wnl while lying, no s/s (sign and symptoms) of pain in it. resident unable to state if she hit her head or not. neuro check is wnl per her norm. hospice called and ordered to send to hospital. Ems (emergency medical services) here at 7:55am, 2 emt (emergency medical technician) transfer with lift pad from wc (wheelchair) to stretcher. hospice to call family. report called to local hospital. R2's Fall Investigation, dated 10/03/24 at 08:06 AM, was reviewed and it documented Notes: Root Cause: resident has dementia and continues to stand and ambulate without walker or assistance of staff. Intervention: Upon return from hospital stay, staff to perform every 15-minute checks until further actions needed. R2's Emergency Department Provider Note, dated 10/03/24, documented [AGE] year-old female with h/o (history of) dementia had an unwitnessed fall at NH (nursing home). Imaging revealed a hip fracture. Pt. (patient) had been on hospice. I contacted pt's family and they opting to revoke hospice to have surgical repair of hip fracture for pain relief. Family opts to stay at this hospital. Anesthesia requested Echocardiogram prior to procedure. Orthopedic, agrees to consult. Plans for surgery Saturday AM most likely. Hospital team agrees to admit. Other incidental findings noted on computed tomography (CT) scan including pulmonary nodules, sclerotic lesion in sacrum, Lumbar (L)1 compression deformity. R2's CT scan, dated 10/03/24, documented IMPRESSION: 1. Acute comminuted impacted intertrochanteric left proximal femur fracture. R2's Procedure Description, dated 10/05/24, documented the operative site was identified and marked prior to taking R2 to the operating room, placed under anesthesia, and then placed onto a fracture table. V13, Surgeon then reduced the left hip to an anatomic alignment, prepped and draped the hip in a sterile fashion. They mad a small incision above the tip of the greater trochanter, dissected through the gluteal fascia, identified the tip of the greater trochanter, the opening [NAME] guidewire was then placed and advanced into the intramedullary canal, images were taken to confirm the position alignment of the wire, placed the gamma nail into the appropriate position, they confirmed positioning, made a small stab incision laterally advanced the trocar down to the lateral aspect of the femur, and then advanced the femoral neck guidewire into a center position, once satisfied with the positioning they got the appropriate length screw, placed the lag screw over the guidewire, placed the top locking screw, and then confirmed the lag screw was locked within the nail. They then utilized an outrigger device made a small stab incision laterally, advanced to the lateral aspect of the femur, drilled and filled out with an appropriate length distal locking screw. All the wounds were then irrigated, the incision was closed with skin staples, and a sterile dressing was then applied. On 10/15/24 at 11:25 AM, V11, Certified Nursing Assistant (CNA) stated she was working on the day R2 fell and broke her hip. V11 said R2 would not stay in her wheelchair, and they had an alarm on it and her bed. She said they would give her washcloths to fold to keep her occupied, try talking with her, and putting her up at the nurse's station and she would still try to get up. V11 stated on the day she fell she was in the shower room trying to give another resident their shower and had them up in the lift when R2's alarm went off and she said she couldn't leave her resident up in the lift to go and check the alarm. V11 said they placed R2 in a public place to be better observed. She said R2 would always take of her shoes and socks, but she wasn't sure if she took them off on this day. V11 said when the alarm was going off, she wasn't sure if someone was there at the nurse's station or not. V11 stated R2 should have never been here at the facility it was the wrong place for her, and she required a lot of 1:1 attention. On 10/15/24 at 11:46 AM, V12, CNA she was working the middle hall on the 200 side. She said she was in the first room on the left-hand side of the hall getting a resident up when she heard an alarm going off. She said she wasn't sure if anyone was at the nurse's station due to no one answered the alarm right away. V12 no one said they were putting anyone up at the nurse's station, so she was unaware there was anyone sitting up there. She said she covered her resident up and put his bed back down in the low position because he was also a fall risk and went out into the hall and that was when she saw R2 lying on her right side on the floor. She said the nurse was out in the dining room passing medications, so she stayed with R2 and hollered down to the nurse and she came right away to assess R2. V12 said R2 stated to her that she thought her hip was broke so they got the Hoyer lift and assisted R2 up and back into her wheelchair so the nurse could finish assessing her. V12 stated usually they are made aware when they place someone at the nurse's station but if anyone said anything she didn't hear it because she was in a room with a resident trying to get them up for breakfast. V12 said sometimes R2 requires 1:1 attention and they will call the family in to help but she said one time the family told them that is why we brought her to you. On 10/15/24 at 3:16 PM, V6, ADON stated R2 was pretty much a 1:1 from the day she came to the facility, and they just couldn't accommodate that. 2. On 10/10/24 at 3:33 PM, R3 was sitting up in his wheelchair by the nurse's station he does not have any access to a call light where he is sitting, there were no nurses or CNAs sitting at the nurse's station, R3 did not have any type of cushion observed in his wheelchair, and there were no sensory/wheelchair alarm observed on his wheelchair. On 10/15/24 at 10:55 AM, R3 was observed sitting in the dining room in his wheelchair. There were no sensory/wheelchair alarm observed and there was no dycem cushion observed in his wheelchair. R3's Admission Record, with an admitted [DATE], documented R3 has diagnoses of but not limited to unspecified nondisplaced fracture of second cervical vertebra, multiple fractures of ribs, and traumatic subdural hemorrhage without loss of consciousness. R3's MDS, dated [DATE], documented R3 is cognitively intact with a BIMS of 13 out of 15 and he requires partial/moderate assist with shower/bathe, dressing of lower body, transfer, independent with upper body dressing, bed mobility, substantial/maximal assistance with putting on/taking off footwear, and he is always continent of bowel and bladder. R3's Care Plan, with admitted [DATE], documented R3 has had an actual fall with no injury Poor Balance, Unsteady gait on 9/24/2024, 10/2/24-resident had another fall from w/c with no injury. Interventions include but are not limited to I have a sensor alarm in my w/c, I have dycem in my w/c, I will be evaluated by PT, and I will be involved in the activity fall program. On 10/15/24 at 10:55 AM, R3 verified for this surveyor he did not have his wheelchair alarm in place and that he didn't have any cushion under him. R3 stated he has had falls since being here at the facility and sometimes they will put his alarms on and sometimes they don't. R3's Admission Morse Fall Scale, dated 06/21/24, documented R3 was a high risk for falls with a score of 55. R3's Electronic Medical Record and Fall/incident assessments July, August, September, and October were reviewed and documented R3 had an unwitnessed fall on 07/03/24, 07/07/24, 8/27/24, 09/01/24, 09/04/24, 10/02/24, and a witnessed fall on 09/24/24. On 10/15/24 at 11:10 AM, V9, CNA was questioned what interventions/assistance is needed to prevent R3 from having falls? V9 stated alarms on his wheelchair and his bed, non-skid socks, activities, and they will also place him at the nurse's station to monitor him. V9 stated R3 hasn't had any falls since he has been working here (a couple of weeks). When this surveyor asked V9 if he could show me R3's alarm he stated it isn't on him now, but he usually does have them on. He said you can see it hanging from the back of his chair when it's on him. There is a pad he sits on and when he tries to stand up the alarm will sound. He said R3 will sometimes get anxious and that is when he starts to get up out of his chair. On 10/15/24 at 12:50 PM, V6, Assistant Director of Nursing (ADON) stated she would expect the staff to make sure the resident's alarms are in place. She said they should know their patients and when they come on shift, they need to be checking to make sure the alarms are in place. V6 said they have been having an increase in falls lately due to some of the new resident's cognitive impairment. The facility's Resident and Staff Safety Policy, dated 02/14/13, documented Resident Safety: The Nursing home will ensure that each resident receives adequate supervision and assistance devices to prevent accidents. The intent of this provision is that the facility identifies each resent at risk for accidents and or falls, and adequately plans care and implements procedures to prevent accidents. The facility's Fall Prevention Policy and Procedure, not dated, documented Purpose To provide guidelines for routine fall risk assessments and fall precautions strategies. It further documented Policy all assessments are to be properly documented and resident specific precautions are to be taken as appropriate

Based on observation, interview, and record review, the facility failed to follow their infection control policy and procedure for 1 of 3 residents (R18) who was on contact isolation precautions for Clostridium difficile (C-diff). Findings include: R18's Face Sheet, with a print date of 07/17/24, documented R18 has a diagnosis of but not limited to enterocolitis due to clostridium difficile. R18's Minimum Data Set (MDS), dated [DATE], documented R18 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 14 out of 15, and requires assistance with his activities of daily living (ADL). R18's Progress Notes, dated 7/2/2024 at 5:41 PM, documented R18 was admitted to the local hospital with pneumonia and C-diff. On 07/17/24 at 11:02 AM, V21, Certified Occupational Therapy Assistant (COTA) was in R18's room on the north end of the 100-hall doing therapy with him using exercise bands. V21 was observed not wearing a gown or gloves. She also was observed to have an over the bed table with her computer, stackable objects, a blue tote with different items in it, and a gripper on the table. On 07/17/24 at 11:10 AM V21, COTA came out of R18's room with the table and the bag. She left the table in the hallway against the wall while she went up to the nurse's station to wash her hands. After she was done doing hand hygiene, she got the table and pushed it down past the nurse's station to the very end of the south 100 hallway without any kind of sanitation/cleaning being done to the table or the content on the table. On 07/16/24 at 12:39 PM, V6, Licensed Practical Nurse (LPN) stated when someone comes back positive for C-diff they will put that person on isolation, and staff will use gloves and gowns when going into the resident's room. On 07/16/24 at 12:56 PM, V7, Certified Nurse's Assistant (CNA) said when someone is on isolation for C-diff they are put in a room by themselves and when the staff go into the room, they are to wear a gown and gloves to be on the safe side. On 07/17/2024 at 9:30 AM, V2, Director of Nursing (DON) stated R18 is the only resident in the facility at this time who has C-diff. She said he just finished up his antibiotic and his stools are starting to be more formed. V2 said when someone is confirmed to have C-diff they will immediately move the resident to another room especially if they both don't have C-diff and she would expect treatment to be started immediately. V2 said she would expect staff to be wearing a gown and gloves when going into a room with someone who has C-diff. On 07/17/24 at 12:46 PM, V2, Director of Nursing stated she would absolutely expect for staff to wear the proper personal protective equipment (PPE) when caring for a resident who is on isolation for C-diff. On 07/18/24 at 2:35 PM, V11, Infection Control Preventionist (ICP) stated if someone was positive for C-diff they would be placed on contact isolation. She would expect any staff who went into the room to give any kind of care to wear a gown and gloves and that includes occupational therapy, she would expect them to do proper hand washing after they were done with the resident's care. She stated staff should not be bringing anything into a room of a resident who has C-diff. If it's bed linens or something like that, they should be disposing of the dirty ones in the dirty linen bin in the resident's room. If they are bringing in any kind of therapy equipment, they should be wiping it down with the appropriate disinfectant wipe before bringing it out of the room. The facility's policy Infection Control Practices Clostridium Difficile, revised date of 03/2004, documented Purpose: The purposes of this procedure are to provide guidelines for the care of persons with Clostridium Difficile, verified by culture or by evidence of positive cytotoxin assay, and to prevent transmission of Clostridium Difficile to others. It further documented Infection Control Protocol and Safety 4. Wear appropriate personal protective equipment (e.g. gloves, gown, mask, eyewear, etc. as necessary) to prevent exposure to spills, splashes of blood or other potentially infectious materials. 5. Maintain clean technique and isolation precautions as indicated. 6. After completion of the procedure, clean, store and/or dispose of equipment and supplies in the appropriate manner as identified per facility infection control policy.

Based on interview and record review the facility failed to provide pain management for one of three residents (R2) reviewed for pain management in the sample of six. This failure resulted in R2 having to endure increased untreated pain for a prolonged period of time Findings Include: R2's Minimum Data Set, dated dated [DATE], documented that R2 is cognitively intact. R2's Pain Care Plan, dated 8/8/23, documented, (R2) has complaint of pain at times related to Osteoarthritis. The nursing (staff) monitors his pain each shift and prn (as needed). He (R2) is offered pain medications as per medical doctor orders. On 1/30/24 at 11:30 AM, R2 stated, I hurt a lot. I have to take pain medicine R2's Physicians Order Sheet (POS), dated 12/29/23, documented that R2 was admitted to hospice with a diagnosis of Colon Cancer. R2's POS, dated 1/18/24, documented, Morphine Sulfate 20 mg (milligrams)/ML (Milliliters) by mouth in the morning every Monday, Wednesday, and Friday prior to Dialysis. R2's POS, dated 1/2/24, documented, Tramadol 50 mg 1 tablet every 4 hours when needed for pain. R2 POS, dated 1/8/24, documented, Morphine sulfate 20 mg/ml give 0.25 ml by mouth every one hour as needed for pain. R2's Nurses Note, dated 1/24/23 at 1:21 AM, documented, Received call from night nurse that evening shift agency nurse must have took med cart (medicine cart) keys home with her. Call placed to (Agency) representative and (Facility's) Pharmacy, message left for both to call this writer back. Call placed to administrator and updated on situation. R2's Nurses Note, dated 1/24/23 at 08:49 AM, documented, Call placed to (Facility's) Pharmacy, request to receive extra set of keys to lock box on each med cart for back up. Faxed over ID information on each lock box, pharmacy will send out keys. R2's Nurses Note, dated 1/24/23 at 9:52 AM, documented, Call placed to agency nurse that worked evening shift prior, to check once she gets home for keys. R2's Nurses Note dated 1/24/23 at 3:50 PM agency nurse returned keys to the facility. On 1/31/24 at 3:00 PM, V2, Director of Nursing, stated, He (R2) did not receive his medications on the morning of 1/24/24 due to not having keys to the lock box. On 1/31/24 at 1:17 PM, V13, Dialysis Nurse, stated, When he returned from the hospital, the family decided to continue dialysis even though he is on hospice, but his pain was not in control. The treatment team decided that he would receive morphine before leaving the facility on Monday, Wednesday, and Friday. On the 24th of January (R2) came to dialysis, but he was complaining of pain and hollering out. I gave him Tylenol, but it did not help. He is usually in a lot of pain. I called the facility, and they stated they didn't have keys to get into the lock box to give him medications. We had to stop his treatment, because he was yelling I want to go home I'm hurting. We sent him back to the facility, but he usually carries a lot of fluid. I set up a dialysis on Saturday, but it wasn't ideal because they were only going to remove the fluid. On 2/1/24 at 11:01 AM, V15, Nurse Practitioner, stated, From my perspective yes he (R2) should have received it (pain medications). The inability to get it, they should have reached out to hospice or our office. If he didn't complete dialysis because of pain that's a problem. I don't believe it is detrimental to him (to miss dialysis). He does very well with his blood pressure and electrolytes. It's not great that he missed a day, but it's not detrimental. The Facility's Pain Policy, undated, documented, 1. To provide effective pain assessment and management that helps remove the adverse psychological and physiological effects of unrelieved pain. It continues, 4. To ensure optimal patient comfort through a proactive pain control plan, which is mutually established with the patient, family, and members of the health care team.

Based on observation, interview and record review, the facility failed to provide complete incontinence care for 4 of 6 residents (R1, R4, R6, R7) reviewed for incontinent care in a sample of 19. Findings include: 1. R6's Care Plan, dated 4/18/22, documents (R6) has an ADL (activity of daily living) deficit related to weakness, removal of R (right) hip, no weight bearing and confusion due to dx (diagnosis) of Dementia. (R6) is unable to communicate her needs to staff. It continues Toileting: (R6) is incontinent of B&B (bowel and bladder). Ensure (R6) is clean and dry by checking on her every 2-3 hours and prn (as needed) when she is hollering out or restless. (R6) is resistive when receiving peri care from staff. It also documents (R6) is always incontinent of bowel and bladder. Staff check (R6) at least every 2 hours. Provide peri care when needed and change. With last revision date 11/29/21. It continues Clean peri-area with each incontinence episode. INCONTINENT: Check every 2-3 hours and prn for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. R6's Minimum Data Set, MDS, dated [DATE], documents that R6 is severely cognitively impaired, frequently incontinent of urine, always incontinent of bowel and requires extensive assist of 2 staff physically for toileting. On 11/15/22 at 10:10 AM, V11, Certified Nursing Assistant (CNA), assisted R6 with incontinent care. R6 was incontinent of urine. V11 folded R6's undergarment between her legs. V11 then, using wash cloth and peri wash, wiped down each side of the groin. V11 then opened R6's labia and wiped. V11 turned R6 onto her right side and cleansed R6's left buttock and partial right buttock. V11 then assisted R6 onto her back and applied clean undergarment. V11 did not cleanse R6's peri area, inner thighs, and entire right buttock. 2. R7's Care Plan, dated 5/5/21, documents that (R7) has functional bladder incontinence r/t (related to) decreased mobility, dx of [CONDITION(S)] and chronic pain. (R7) does not use the toilet or bedpan, she will inform staff when she needs to be changed. Incontinent of bowel also. It continues Clean peri-area with each incontinence episode. R7's MDS, dated [DATE], documents that R7 is always incontinent of urine and bowel and totally dependent on 2 staff physically for toileting. On 11/15/22 at 10:39 AM, V11 assisted R7 with incontinent care. R7 was incontinent of urine. V11 folded R7's undergarment between her legs. V11 then, using wash cloth and peri wash, wiped down each side of the groin. V11 then opened R7's labia and wiped. V11 turned R7 onto her left side and cleansed R7's right buttock and partial left buttock. V11 then applied lotion to R7's right buttock and partial right buttock. V11 then assisted R7 onto her right buttock and applied lotion to R7's left buttock. V11 then assisted R7 onto her back and applied clean undergarment. V11 did not cleanse R7's peri area, inner thighs, and entire left buttock. 3. R1's Care Plan, dated 9/14/2021, documents (R1) has self-care deficit r/t [CONDITION(S)]. She is able to feed herself, wash her face and hands and brush her teeth. She is in Restorative Hygiene and Feeding programs. (R1) is dependent on staff for all other ADL'S. It continues TOILET USE: Incontinent of B&B. Check at least q 2 hours and prn for incontinence. Wears incontinent briefs. R1's MDS, dated [DATE], documents that R1 is severely cognitively impaired, always incontinent of bowel and urine and is totally dependent physically on 2 staff for toileting. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/14/22 at 1:31 PM V15, CNA, and V13, CNA, assisted R1 with repositioning and toileting. V15 and V13 assisted R1 into the bed. V13 opened R1's undergarment and folded it between her legs revealing a moderately urine soiled incontinent brief. V15 then using a washcloth and peri wash cleansed R1's lower abdomen, each side of R1's groin and inner labia. V15 and V13 then assisted R1 onto her right side and cleansed R1's left buttock. V15 and V13 then assisted R1 onto her back and applied cleaned incontinent brief. V15 and V13 did not cleanse R1's outer labia and R1's right buttock. 4. R4's Care Plan, dated 3/9/21, (R4) has an ADL self-care performance deficit r/t Impaired balance, Muscle weakness and [CONDITION(S)] It continues TOILET USE: (R4) requires an extensive assist of 2 staff for toileting. It also documents (R4) has urgency/frequency bladder incontinence r/t Renal mass/lesion. INCONTINENT: Check and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. R4's MDS, dated documents that R4 is always incontinent of urine and requires extensive assist of 2 staff physical assist. On 11/17/22 at 10:40 AM V11 and V14, CNA, assisted R4 with incontinent care. R4 was incontinent of urine. V11 and V14 opened R4's brief and rolled between R4's leg revealing a heavily soiled undergarment. Using a washcloth and peri wash V14 cleansed R4's groin and peri area. V11 then cleansed R4's labia. V11 and V14 then turned R4 onto her left side. V11 then using peri wash and a washcloth cleansed R4's right buttock and partial left buttock. V11 and V14 then turned R4 onto her back and applied clean undergarment. On 11/17/2022 at 1:43 PM V13, Licensed Practical Nurse (LPN), stated that she expects the staff to cleanse all area of incontinence. stated that she would expect the staff to turn the residents to both sides and cleanse the entire buttock. V13 stated that she would expect the staff to cleanse all areas including entire buttocks, inner and outer labia, groin, and peri area. On 11/17/2022 at 1:00 PM V1, Administrator, stated that she expects all areas that could be potentially soiled to be clean. V1 stated that this includes inner thighs and residents to be turned side to side and clean entire buttocks. The facility's Perineal policy, dated 2/6/12, documents Procedure: a. Female Perineal Care: b. Ask resident to separate and flex knees. If she is unable to spread her legs and flex her knees, the perineal area can be with the resident on the side with legs flexed. d. Wet wash cloth and apply soap or peri wash to wet wash cloth. e. Use one glove to stabilize and separate the labia, with other hand, wash from front to back. f. wet wash cloth and rinse g. pat dry with dry wash cloth or towel.

Based on observation, interview, and record review, the facility failed to ensure call lights were within residents' reach and easily accessible for 2 of 5 residents (R13, R28) reviewed for accommodation of needs in a sample of 19. Findings include: 1. R13's Face Sheet, with a print date of 11/17/22, documents R13 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's Minimum Data Set (MDS), dated [DATE], documents R13 is moderately cognitively impaired, and requires extensive assistance, 2 plus person physical assist with bed mobility, dressing, toilet use, and personal hygiene. She also requires 2 plus person physical assist with transfer. R13's Care Plan, with an admitted [DATE], documents The resident has an Activities of Daily Living (ADL) self-care performance deficit. It further documents TOILET USE: The resident is able to: extensive assistance of two staff members. TRANSFER: The resident is able to: extensive assistance of two staff and a sit to stand. It also documents Encourage the resident to use bell to call for assistance. On 11/14/22 at 9:50 AM, R13 was sitting in a recliner in her room. One call light was wrapped around the far bedrail, and the other call light was draped over the other bedrail and out of R13's reach. On 11/16/22 at 9:10 AM, R13 was sitting in her recliner in her room. One call light was wrapped around the far bedrail, and the other call was draped over the other bedrail and out of R13's reach. On 11/16/22 at 10:48 AM, V10, Certified Nursing Assistant (CNA) stated R13 can use her call light when she needs assistance. 2. R28's Face Sheet, with a print date of 11/17/22, documents R28 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R28's MDS, dated [DATE], documents R28 is cognitively intact, and requires extensive assistance, 2 plus person physical assist with bed mobility, transfer, walking in room, locomotion on unit, toilet use, and personal hygiene. R28's Care Plan, with an admitted [DATE], documents the resident has an ADL self-care performance deficit, TOILET USE: The resident is able to: extensive assistance of two staff with walker and gait belt. TRANSFER: The resident is able to: she is an extensive two person with walker and gait belt and encourage the resident to use bell to call for assistance. It further documents Ensure call light is within reach at all times and encourage her to use it when needing assistance. On 11/16/22 at 10:15 AM, This surveyor was on the 200 hallway and heard R28 calling out and asking if there was a nurse out there. This surveyor went to R28's door to talk with R28. R28 was sitting in a recliner in her room, she stated I can't reach my buzzer. R28's call light was lying over on her bed, and out of R28's reach. At this time V18 came in the room and R28 told them that she couldn't get her call light and she needed help getting to the bathroom. V18 then gave R28 her call light and went to get a CNA to help R28 to the bathroom. On 11/17/22 at 09:38 AM, V3, Nurse Manager/Licensed Practical Nurse (LPN) stated the call lights need to be always in reach of the residents. On 11/17/22 at 10:53 AM, V1, Administrator stated the call lights should be always within reach. The facility's Policy and Procedure for Call light, use of, with no date noted, documents Purpose 1. To respond promptly to resident's call for assistance. 2. To assure call system is in proper working order. It further documents 8. When providing care to residents be sure to position the call light conveniently for resident to use.

Based on observation, interview and record review the Facility failed to ensure hand hygiene was performed prior to and during a Peripherally Inserted Central Catheter (PICC) dressing change as well as while providing incontinent care to prevent the spread of infection for 3 of 12 residents (R18, R6, R34) reviewed for infection control in the sample of 19. Findings include: 1. R18's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/15/2022 at 11:06 AM, V12, Registered Nurse (RN) picked up a bag of medication from the medication storage area and entered R18's room to administer R18's Intravenous (IV) medication. R18 was observed with a PICC line located in R18's left arm. The transparent dressing was soiled with blood underneath. V12 stated she is going to change R18's dressing. Without the benefit of hand hygiene, V12 applied nonsterile gloves and proceeding to pick up a plastic bag from the bottom of the trash can. V12 then began removing R18's PICC line dressing. V12 touched the trash bag again and threw away the old dressing. V2, Director of Nursing entered to room to assist. V12 began palpating the PICC line site with her gloves and stated, Somethings not right. V12 threw the non-sterile gloves away, opened the sterile dressing kit and donned sterile gloves, without the benefit of hand hygiene. V18 cleansed the PICC site and again stated, something is not right. V12 then used her sterile gloves to grab a non-sterile package from a chair behind her. V2 opened the package for V18 so she could apply the cap. R18's Progress Notes dated 11/15/22 at 12:10 PM documents, PICC line had blood under PICC line drsg. (dressing). Dressing removed and cleaned. New drsg applied. New injection caps applied. On 11/15/2022 at 2:10 PM, V18 donned gloves, without the benefit of hand hygiene and hooked R18's IV tubing to the lumen of the PICC and began the infusion. On 11/16/2022 at 11:38 AM, V2 stated, There were some issues with infection control during the dressing change. (V12) should have performed hand hygiene before opening the sterile package and donning the sterile gloves. I would expect hand hygiene, even with alcohol rub, between glove changes. The Facility's Midline Catheter-Dressing Change Policy/Procedure, undated, documents, 3. Perform hand hygiene. 4. Assemble equipment and open packages. 5. Explain to patient. Provide privacy. 6. Apply non-sterile gloves. 7. Open dressing kit using aseptic technique. 8. Put on mask. 9. Stabilize the catheter and remove old dressing from site and dispose of in plastic bag. 10. Remove securement device used to stabilize catheter. 11. Remove non-sterile gloves and dispose of in plastic bag. Perform hand hygiene. 2. On 11/15/22 at 10:10 AM V11, Certified Nursing Assistant, CNA, assisted R6 with incontinent care. R6 was incontinent of urine. V11 folded R6's undergarment between her legs. V11 then, using wash cloth and peri wash, cleansed R6 inner labia and groin. V11 changed gloves and assisted R6 onto her left side and cleansed R6's left buttock and partial right buttock. V11 then removed R6's soiled undergarment. V11 then assisted R6 onto her back and with the same soiled gloves applied R6's clean undergarment, pulled covers up and raised R6's bed with the remote. 3. On 11/14/22 at 12:50 PM V14, CNA, and V11, assisted R34 with peri care. R34 had a bowel movement. V14, operating the controls, assisted R34 into a standing position. V11, using wash cloths and peri wash cleanse R34's anus and buttocks. Using the same soiled gloves V11 pulled up R34's incontinent brief and pants up. V14 pulled R34 back and towards chair. V11, using the same soiled gloves, grabbed hold of the handrails, and pushed R34's wheelchair beneath him. V14 then lowered R34 into the wheelchair. The facility's Hand-Washing policy, dated 2/17/22, documents 1. Purpose: To remove germs from hands and prevent the spread of infection. b. Handwashing should be done at the following times: ii Before and after caring for each resident iii. After contact with blood, body fluids and contaminated items iv. Whenever hands are obviously soiled.

A. Based on observation, record review and interview, the Facility failed to implement fall interventions and provide safe transfers for 2 of 5 residents (R1, R3) reviewed for falls in the sample of 15. This failure resulted in R3 sustaining a fracture of the right proximal femur that required emergency treatment. Findings include: 1. R3's current Cumulative [DIAGNOSES REDACTED]. R3's Minimum Data Set (MDS), dated [DATE] and 9/23/2014 documents that R3 is severely cognitively impaired in decision making, requires extensive assistance for transfers, and has unsteady balance from sitting to standing and surface to surface transfers. The Incident/Accident Report, dated 12/31/2013 at 5:20 AM, documents, in part, that R3 was "found on the floor between the recliner and over bed table. Staff heard the noise when (R3) fell . Checked sensor pad which was on, but cord was malfunctioning and would not sound at times until moved cord around. Complained of pain to right upper thigh, with right foot rotating outward." The Report of Investigation for R3, dated 12/31/2013 documents, in part, "(R3) sent to the (local emergency department) for further evaluation and treatment. (R3) was being admitted to the hospital for pneumonia and fracture of the right hip". The X-Ray Report, dated 12/31/2013, documents R3 suffered a "Moderate displaced comminuted intertrochanteric fracture of the right proximal femur". The Incident/Accident Report for R3 dated 5/17/2014 at 9:50 AM, documents R3 "slid off of the commode after defecating very large BM (bowel movement), lying on left side, laceration noted to left eye, left arm and elbow. Staff (E7, CNA) in bathroom with (R3)." The statement from E7 documented on the Report was, "I had the resident (R3) on the stool in the restroom. I went to turn around to get a washcloth. When I was turning back around she started falling. I couldn't get to her in time." Additional comments documented on the Incident/Accident Report for 5/17/2014 are, "Staff was instructed to keep supplies in front of them so they do not have to turn around to get them. (R3) has episodes of non-responsiveness and they usually occur on the toilet. Staff instructed to stay with (R3) entire time she is in the bathroom. This is the second occurrence, did occur one other time in February on BSC (bedside commode), did not fall, went unresponsive after large BM." The Incident/Accident Report, dated 11/11/2014 at 6:50 AM, documents, in part, "This nurse (E8, Registered Nurse) was called down to (R3's) room by CNA (E7). Upon entering room, (R3) observed to be sitting on floor against chair. Two red marks visible on back". The Investigation of Incident, dated 11/11/2014 documents, in part, "Type of safety device/care planned: Use 2 people to transfer, as well as gait belt." The investigation documents E7 transferred R3 with one assist, without a gait belt and R3's knees gave out. E7 reported she never transfers R3 with 2 assist using a gait belt, and was unaware where to find out what type of assistance R3 required. R3's Care Plan, updated 11/11/2014, documents, in part, "has history of falls, would always transfer without assist. Does not remember to use the call light, is confused and forgetful. Has bouts of unresponsiveness." The interventions documented, in part; "Sensor pad to bed and wheelchair. Check placement and function every shift. Do not leave on toilet unattended. Have all supplies gathered before care. Continue to remind CNA's (R3) is a 2 assist and gait belt with all transfers." On 11/25/2014, at 1:15 PM, R3 was transferred with the assist of E5 and E6, CNA's with the use of a gait belt. R3 was very confused and required extensive assistance during the transfer with minimal weight bearing to the lower extremities. On 11/26/2014, at 2:00 PM E2, Director of Nursing (DON) was interviewed about R3's falls. E2 stated, "Well, it is what it is." The facility's policy and procedure revised 4/2014, entitled, "Resident and Staff Safety Policy' documents, in part, "the facility identifies each resident for accidents and/or falls; and adequately plans care and implements procedures to prevent accidents. ALARMS: Make sure that the unit is turned on and functioning properly prior to each use. Check the battery indicator light if the unit has one and change batteries as needed. All residents who require weight bearing or hands on assistance with transfers and/or ambulation will be transferred and/or ambulated with the use of a safety (gait) belt, unless it is medically contraindicated." 2. The current Cumulative [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] and 8/26/2014 documents R1 is severely impaired with cognition, requires assistance with transfers and has an unsteady balance from sitting to standing, walking and surface to surface transfers. The Incident/Accident Reports for R1 documents falls on 1/19/2014, 2/28/2014, 3/30/2014 and 8/16/2014, as R1 was trying to transfer himself or attempting to stand up without assistance. The Incident/Accident Report for R1 dated 8/16/2014 documents "(R1) was standing in doorway, fell back onto buttocks before (E5, Certified Nurses Aide) could get to him, landed on buttocks, then rolled onto back. No apparent injury at this time. Was the alarm present and intact? Yes. Sounding? No. Why not? Not on. Must double check all alarms are on. Staff counseled on importance of ensuring alarms are on and functioning before leaving the room." B. Based on observation, record review and interview, the Facility failed to maintain equipment in good condition to prevent accidents for 1 of 15 residents (R12) reviewed for equipment safety in the sample of 15. Findings include: 1. On 11/25/14 and 11/26/14, R12 was observed lying in bed with raised, bilateral 1/2 side rails at the top of his bed. On 11/26/14 at 1:30 PM, it was noted that the 1/2 rail located on the right side of R12's bed was very loose and wiggled from side-to-side and front-to-back at least 5 inches. E1, Administrator, was present in the room and stated that the rail should not be able to move that much. E9, CNA, stated in an interview on 12/3/14 that R12 only uses his siderails to assist the staff when they turn and reposition him. E9 said that R12 never uses the rails independently and only with staff present. E9 said that R12's condition is declining and he only grabs the rails to assist in turning and repositioning "once in awhile now". R12's current Physician order [REDACTED]. R12's POS documents: "11/7/14, Top 1/2 siderail up while staff is present and providing care, to maintain side position". R12's "Restraints: Side Rail Utilization Assessment", dated 7/3/14, documents "resident states he had side rails on his bed at home and he needs them to move around". R12's MDS, dated [DATE], documents a BIMS score of 10, with 15 being the highest cognitive level of functioning. The MDS further documents that R12 requires the extensive assistance of two or more staff members for transfers and toilet usage; and the extensive assistance of one staff member for bed mobility. The Facility policy entitled "Resident and Staff Safety Policy", documents "General Guidelines for Resident Safety: report all faulty equipment to maintenance and remove from use".

Based on interview and record review the facility failed to develop a written policy to ensure the facility investigates injuries of unknown origin and notifies the Department immediately after an allegation of abuse is reported, failed to operationalize it Abuse Policy by not reporting allegations of abuse immediately to the Administrator and allowing Certified Nurses Aides (CNA) to have direct contact with residents after potential incidents of abuse and failed to timely investigate injuries of unknown origin. This has the potential to affect all 73 residents living in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 12/27/12, the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication regarding abuse and injuries of unknown origin. Findings include: 1. The facility's Procedures of Prevention of Abuse, dated 1999 documented "Pattern Assessment: At least quarterly, the Quality Management committee will review concern identification reports, accident reports, incidents reports, missing items reports, and safety committee reports to assess possible patterns or trends of suspicious bruising of residents, unexplained accidents, or other occurrences that my constitute abuse, neglect or thefts. Based on an assessment of the reports, the Quality Management committee will further investigate and/or determine whether a change in facility practices is warranted." This policy did not address how the facility would immediately identify injuries of unknown origin, such as suspicious bruising of residents, as potential allegations of abuse. The facility's Procedures of Prevention of Abuse, dated 1999 documented under the section "Initial Reporting of Allegations: Within twenty-four hours after the occurrence, a written report shall be sent to the Department of Public Health." The policy did not address the Department should be notified immediately of all allegations of abuse. The facility's Procedures of Prevention of Abuse, dated 1999 documented "Protection of Residents - Employees of this facility who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee. Employees accused of possible mistreatment shall not complete the shift as a direct care provider to residents." The facility's Procedures of Prevention of Abuse dated 1999 documented "Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to the administrator." The facility's Procedure of Prevention of Abuse, Section "Pre-Employment Screening of Potential Employees" documented "Prior to new employee staring a work schedule, this facility will: Initiate a reference check from previous employer (s), in accordance with facility policy; Check the Illinois Nurse Aide Registry on any individual being hired for a Certified Nurse's Aide position; and File an Illinois State Policy Healthcare Worker Background Check application on any individual being hired for a Certified Nurse's Aide position." 2. On 12/18/12 at 4:00 PM, E2, Assistant Administrator, was questioned regarding if the facility had any abuse allegations within the last year. E2 stated the facility had no allegations of abuse within the last year; however, an Investigation of Complaint was completed in November 2012. E2 again stated no allegations of abuse had been reported to her within the last year. The Investigation of Complaint, dated 11/9/12 documented that at 5:00 AM, E2 received a telephone call from E32, Licensed Practical Nurse (LPN). E32 reported E31, Dietary Aide, was standing by the time clock and overheard someone say, "Shut up, be quiet, and I don't know." E32 stated E31 reported the allegation to her and stated the residents 'should not be talked to that way. It's not right.' The Complaint documented, "(E32) stated 'that is all I know, I do not know if it is abuse or not." The Complaint documented, " I (E2) told (E32) I would be in shortly to investigate the situation." The Complaint documented E2 came into the facility, notified E34, Certified Nurse's Aide (CNA), and E33 CNA of the allegation and removed them from direct care. E2 counseled E32 on the abuse policy regarding removing the alleged abusers from direct care immediately. The Complaint documented E31 reported the allegation to E32 and did not report the allegation to the E1, Administrator. The Complaint did not document at what time E31 alleged the incident occurred. There was no documentation regarding if this allegation was reported to the Department as an allegation of abuse. There was no documentation regarding if other alert and oriented residents were questioned regarding if they had any issues with staff treatment. On 1/3/13 at 9:40 AM, an interview was conducted with E3, Director of Nurses, DON. E3 stated basically E31 overheard a conversation between R37 and E33 and E34. E3 stated they did not conclude any abuse occurred; however, E3 did counsel E32 regarding not removing E33 and E34 from direct resident care after the allegation was made. 3. R2's Skin Issue Details Report dated 4/30/12 at 5:40 AM documented he had a 5 1/2 centimeter (cm) by 1 3/4 cm black and blue bruise on his upper left thigh. R2 was unsure how the bruise occurred. The Occurrence Report dated 4/30/12 documented R2's Physician and POA had been notified of the bruise. There was no documentation regarding if E1, Administrator, had been notified of this bruise. On 12/21/12 at 9:45 AM, an interview was conducted with E3. She stated there was no further documented investigation regarding R2's bruise of unknown origin. 4. On 12/20/12 at 3:00 PM, a review of E22's, E23's, E24's, E25's and E26's, Certified Nurse's Aides (CNA's),pre-employment screening was completed. E22 was hired on 8/27/12 and the facility did not conduct a finger-print check to determine if she had any criminal history. E23, CNA was hired on 10/10/12 and the facility did not conduct reference checks with previous employers and a finger-print check to determine if she had any criminal history which would prevent her from employment. The facility did not conduct reference checks with previous employers for E24, E25 and E26 prior to their employment. On 12/20/12 at 3:25 PM, an interview was conducted with E27, Office Manager. E27 stated she read the Health Worker Registry wrong and did not conduct finger-print based criminal background checks on E22 and E23. E27 stated reference checks were not completed on E23, E24, E25, and E26. 5. On 12/19/12 from 4:15 PM until 4:40 PM, abuse prohibition interviews were conducted. E24 stated she would let the nurse and E3 know if she witnessed or became aware of an allegation of abuse. E25 stated she would let her Charge Nurse know if she witnessed abuse or became aware of an allegation of abuse. These employees did not state they would immediately notify E1 of an allegation of abuse. 6. In an incident report written by E36, LPN, and dated 7/20/12 at 10:10 PM, E36 documented; Called to R4's room by E37, CNA. Multiple bruising noted on inner thighs. 7.0cm X 5.5cm bruise to right back rib area, 6.0cm X 3.5cm to right outer breast, and 6.0cm X 2.5cm to left back rib area. R4 last toileted at 10:00 PM. R4 stated, don't ask me what happened, I didn't know they were there." On 7/21/12, at 12:20 PM, E12, LPN, documented that "R4's daughter reported she had previously seen her mother scratching down there. She's on Aspirin and bruises easily." On 7/23/12 E3 documented "E12 states the bruising matches R4's finger prints". The incident report documented no further information that an investigation had been done for this injury. On 12/19/12 at 11:15 AM, in an interview E3 stated that she had reviewed R4's incident report of 7/20/12. E3 stated "R4's bruises were documented on the incident report and the report was put in my mail box. Since 7/20/12 was a Friday, I did not see the report until Monday 7/23/12. I thought the bruises were caused by R4 herself, since R4's daughter said she had been scratching between her legs. I did not investigate the rib and breast bruises for possible abuse of R4." E3 stated "I would consider the bruises to R4's ribs and breast as bruises of unknown origin. I did not know I had to do an investigation on bruises of unknown origin." E3 stated she did tell the administrator about the incident/bruising of R4 on 7/23/12, but did not know to notify the Department, or do any further investigation. 7. An incident report dated 9/5/12 at 11:45 AM for R1, written by E14, LPN, and E14 documented "R1 was sitting at the dining table when bruises were noted on both hands by another staff member, E30 Registered Nurse, RN. E30 stated that the bruises were not there the day before." Measurements were documented as; Left hand between thumb and fore finger 3.5cm X 3.0cm and Right hand 4.0cm X 3.0cm. E3 documented on 9/5/12, skin fragile, bruises easily. Unable to state how occurred. The incident report documented no further information that an investigation had been done for this injury. 8. Review of an incident report for R1, written by E15, LPN, on 9/26/12 at 7:20 PM, documented, daughter came to nurses station to ask about bruise to left leg. Upon entering room, noted a 2.5cm X 3.0cm deep purple bruise to left outer calf and a 1.0cm X 1.0cm bruise to left outer ankle. Resident unaware of cause. The incident report documented no further information of an investigation being done for this injury. On 12/19/12 at 11:15 AM, in an interview with E3, she stated that she did not do any further investigating of the previous two incidents; of how R1's hands became bruised on 9/5/12 or how R1's left leg became bruised on 9/26/12. E3 stated "it's like I said earlier, the report was put in my box, and when I reviewed it, I was not aware that bruises of unknown origin had to be reported and investigated immediately. E3 stated "currently the facility has no system in place for reporting injuries of unknown origin immediately to the Administrator. Resident injuries are documented by the nurses on an incident report and put in my mail box for later review." 9. During tour of the facility on 12/18/12, at 9:40 AM, R7 had two small scabbed [MEDICAL CONDITION] to both shins and a purple bruise to the outside of her right knee. On 12/18/12, at 11:17 AM, Z1, family member was interviewed related to R7's care at the facility. Z1 stated, "She (R7) tries to crawl out of bed." Two half siderails were in the middle of R7's bed in the raised position. Throughout the day on 12/18/12, at 9:40 AM, 11:17 AM, 12:10 PM, 12:50 PM, and 1:55 PM, R7 was observed flexing and extending her lower extremities, and turning her lower body from side to side, often touching or resting them on the siderails. On 12/19/12, at 10:55 AM, a skin check was completed for R7 with E13, CNA. E13 was interviewed and asked how R7 obtained the scabbed areas on her legs and the bruise to her right outer knee. E13 replied, "I don't know." E13 reported she was unaware the areas were there until now. The Nurses Notes for 12/2012 fail to document any scabbed [MEDICAL CONDITION] to R7's lower extremities or the bruise to her outer right knee. The Treatment Record for 12/2012 has no documentation related to the scabbed areas to the lower extremities or the bruise to the righter outer thigh. The Accident/Incident Log was reviewed for 11/12 and 12/12. No documentation related to the bruise or scabbed areas to R7's lower extremities is noted. 10. During tour of the facility on 12/18/12, at 9:40 AM, with E12, LPN, R3 was asleep in a reclined geriatric chair. Multiple dark purple bruises were noted to the top of R3's hands. E12 reported R3 had a recent fall from a wheelchair. R3 had flaccid paralysis of all extremities and facial muscles and was unable to communicate verbally. On 12/10/12, the Nurses Notes for 12/2012 were reviewed. There was documentation in the Nurses Notes for December related to the current bruising of R3's hands. The Treatment Record for December 2012 was reviewed. There was no documentation in the Treatment Record related to the bruises to R3's hands. On 12/20/12, the facility's Accident/Incident Logs were reviewed for 11/2012 and 12/2012. On 11/01/12, R3 fell forward out of her wheelchair, hit her head and was sent to the local hospital for evaluation. The Admission Nursing History/Assessment, dated 11/06/12, documents R3 was readmitted with purple bruises to both hands with [MEDICAL CONDITION] and bruising around her left orbit (eye area). The physician's orders [REDACTED]. On 12/20/12, at 11:05 AM, E18, LPN was interviewed about the bruising to R3's hands. E18 stated, "I have not noticed them or seen them. I'm not sure with her." E18 did not go examine R3's hands and then wheeled the medication cart into the dining room. 11. The Resident Census and Conditions of Residents, CMS 672, dated 12/19/2012 documents that the facility has 73 residents living in the facility. The Immediate Jeopardy was identified to have begun on 4/30/12, when staff failed to report R2's bruise of unknown origin immediately to E1 and the Department and failed to thoroughly investigate this injury of unknown origin to rule out potential abuse. The facility continued to fail to investigate injuries of unknown origin, report allegations of abuse immediately to the Administrator and Department and allowed CNA's to have direct contact with residents after potential abuse incidents. On 12/19/12, at 4:45 PM, E1, E2, Assistant Administrator, E3 and E4, Assistant Director of Nurse's, were informed of the Immediate Jeopardy. Based on observation, interview and record review, the facility took the following actions to remove the Immediate Jeopardy: 1. The facility will immediately in-service all staff on facility's policies regarding abuse, how to report and investigate incidents. In-servicing stared on December 20, 2012 and completed on 12/21/12. 2. The Director of Nursing and designated licensed staff conducted heat to toe body checks of all residents in facility beginning the evening of 12/20/12 and completing the morning of 12/21/12 with the exception of 10 residents who are alert and oriented and refused the head-to-toe body check. 3. On 12/27/12 a Reporting and Investigation of Incident one page guide was posted at each nurse's station as well as the break room. The form includes the Administrator, Assistant Administrator and Director of Nursing cell/telephone numbers. 4. Verbal interviews with staff regarding abuse policies, who to report abuse to, investigation procedures etc. will be conducted on each staff member at least two times during the next seven days and then intermittently to ensure that all staff know the policies and procedures. 5. On 12/27/12 the facility has reviewed the grievance/concern reporting process with the residents individually and in small group settings, as well as mailed a copy of the grievance/concern reporting policy to the legal guardian/responsible party, or family member. 6. The facility will maintain a log to track, trend and analyze injuries of unknown origin which will be reviewed and discussed by the Quality Assurance Committee. 7. If, after an investigation, abuse has been ruled out, the injures will be referred to the Care Plan Coordinator to implement or amend the Care Plan to reduce the risk of re-injury.

Based on observation, record review and interview the facility failed to identify and investigate injuries of unknown origin as potential abuse, failed to immediately report injuries of unknown origin to the Administrator and to the Department, failed to fully investigate injuries of unknown origin and failed to remove staff from direct care when involved in potential abuse incidents. This has the potential to affect all of the 73 residents living in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 12/27/12, the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication regarding abuse and injuries of unknown origin. Findings include: 1. A review of the physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented R4 was severely cognitively impaired. The Care Plan dated 9/6/12, documented R4 "has short term memory deficits. I am told things but do not remember, at times I do not even know where I am." In an incident report written by E36, Licensed Practical Nurse, LPN, and dated 7/20/12 at 10:10 PM, E36 documented; Called to R4's room by E37, Certified Nurses Aide, CNA.. Multiple bruising noted on inner thighs. 7.0 centimeter (cm) X 5.5cm bruise to right back rib area, 6.0cm X 3.5cm to right outer breast, and 6.0cm X 2.5cm to left back rib area. R4 last toileted at 10:00 PM. R4 stated, don't ask me what happened, I didn't know they were there." On 7/21/12, at 12:20 PM, E12, LPN, documented that "R4's daughter reported she had previously seen her mother scratching down there. She's on Aspirin and bruises easily." On 7/23/12 E3, Director of Nursing, DON, documented "E12 states the bruising matches R4's finger prints". The incident report documented no further information that an investigation had been done for this injury. On 12/19/12 at 11:15 AM, in an interview E3, stated that she had reviewed R4's incident report of 7/20/12. E2 stated "R4's bruises were documented on the incident report and the report was put in my mail box. Since 7/20/12 was a Friday, I did not see the report until Monday 7/23/12. I thought the bruises were caused by R4 herself, since R4's daughter said she had been scratching between her legs. I did not investigate the rib and breast bruises for possible abuse of R4." E3 stated she would consider the bruises to R4's ribs and breast as bruises of unknown origin and stated "I did not know I had to do an investigation on bruises of unknown origin." E3 stated she did tell the Administrator about the incident/bruising of R4 on 7/23/12. E3 stated she did not know to notify the Department. 2. R1's POS dated 12/1/12 documented a [DIAGNOSES REDACTED]. R1's MDS dated [DATE] documented R1 was severely cognitively impaired, and was an assist of 2 staff for all mobility and hygiene needs. Review of an incident report for R1, written by E14, LPN, was dated 9/5/12 at 11:45 AM. E14 documented "R1 was sitting at the dining table when bruises were noted on both hands by another staff member, E30 Registered Nurse, RN. E30 stated that the bruises were not there the day before." Measurements were documented as; Left hand between thumb and fore finger 3.5cm X 3.0cm and Right hand 4.0cm X 3.0cm. E3 documented on 9/5/12, skin fragile, bruises easily. Unable to state how occurred. The incident report documented no further information that an investigation had been done for this injury. Review of an incident report for R1, written by E15, LPN, on 9/26/12 at 7:20 PM, documented, daughter came to nurses station to ask about bruise to left leg. Upon entering room, noted a 2.5cm X 3.0cm deep purple bruise to left outer calf and a 1.0cm X 1.0cm bruise to left outer ankle. Resident unaware of cause. The incident report documented no further information of an investigation being done for this injury. On 12/19/12 at 11:15 AM, in an interview with E3, she stated that she did not do any further investigating of how R1's hands became bruised on 9/5/12 or how R1's left leg became bruised on 9/26/12. E3 stated "it's like I said earlier, the report was put in my box, and when I reviewed it, I was not aware that bruises of unknown origin had to be reported and investigated immediately. E3 stated "currently the facility has no system in place for reporting injuries of unknown origin immediately to the Administrator. Resident injuries are documented by the nurses on an incident report and put in my mail box for later review." 3. R2's Skin Issue Details Report dated 4/30/12 at 5:40 AM documented he had a 5 1/2 cm by 1 3/4 cm black and blue bruise on his upper left thigh. R2 was unsure how the bruise occurred. The Occurrence Report dated 4/30/12 documented R2's Physician and POA had been notified of the bruise. There was no documentation regarding if E1, Administrator had been notified of this bruise. On 12/21/12 at 9:45 AM, an interview was conducted with E3. She stated there was no further documented investigation regarding R2's bruise of unknown origin. 4. On 12/18/12 at 4:00 PM, E2, Assistant Administrator was questioned regarding if the facility had any abuse allegations within the last year. E2 stated the facility had no allegations of abuse within the last year; however, an Investigation of Complaint was completed in November 2012. E2 again stated no allegations of abuse had been reported to her within the last year. The Investigation of Complaint, dated 11/9/12 documented that at 5:00 AM, E2 received a telephone call from E32, LPN. E32 reported E31, Dietary Aide, was standing by the time clock and overheard someone say, "Shut up, be quiet, and I don't know." E32 stated E31 reported the allegation to her and stated the residents 'should not be talked to that way. It's not right.' The Complaint documented, "(E32) stated 'that is all I know, I do not know if it is abuse or not." The Complaint documented, " I (E2) told (E32) I would be in shortly to investigate the situation." The Complaint documented E2 interviewed E32 regarding the incident. The Complaint documented, "(E32) informed me (E31) didn't really know but thought it was (E34, CNA) and (E33, CNA). At this time, I pulled (E33) and (E34) off the floor and informed them that someone thought they heard them say to a resident shut up, be quiet and I don't know. I instructed (E34) and (E33) to write up a statement of what happened." The Complaint did not document at what time E31 alleged the incident occurred. The Complaint documented, "At approximately 0700, E3 and I (E2) interviewed (E32). When I asked (E32) what happened this morning she stated I was passing my meds on west hall and (E31) came to me and said she was standing at the time clock and heard someone say shut up, be quiet, and I don't know, and then they carried on with their conversation. (E32) stated ' (E31) asked me who the aides were on that side of the building and I told her (E34) and (E33) was helping. (E31) said something else about her mom being here, but I didn't catch all that, she also said that residents do not need to be talked to that way. So then I called (E2) to let her know what was reported to me.' I counseled (E32) if she though it may be abuse she should have pulled the 2 girls off the floor immediately. (E32) stated she wasn't for sure who even said what so I wasn't sure what to do that is why I called you." There was no documentation regarding if this allegation was reported to the Department as an allegation of abuse. There was no documentation regarding if other alert and oriented residents were questioned regarding if they had any issues with staff treatment. On 1/3/13 at 9:40 AM, an interview was conducted with E3. E3 stated basically E31 overheard a conversation between R37 and E33 and E34. E3 stated they did not conclude any abuse occurred; however, E3 did counsel E32 regarding not removing E33 and E34 from direct resident care after the allegation was made. 5. During tour of the facility on 12/18/12, at 9:40 AM, R7 had two small scabbed [MEDICAL CONDITION] to both shins and a purple bruise to the outside of her right knee. On 12/18/12, at 11:17 AM, Z1, family member was interviewed related to R7's care at the facility. Z1 stated, "She (R7) tries to crawl out of bed." Two half siderails were in the middle of R7's bed in the raised position. Throughout the day on 12/18/12, at 9:40 AM, 11:17 AM, 12:10 PM, 12:50 PM, and 1:55 PM, R7 was observed flexing and extending her lower extremities, and turning her lower body from side to side, often touching or resting them on the siderails. On 12/19/12, at 10:55 AM, a skin check was completed for R7 with E13, CNA. E13 was interviewed and asked how R7 obtained the scabbed areas on her legs and the bruise to her right outer knee. E13 replied, "I don't know." E13 reported she was unaware the areas were there until now. The Nurses Notes for 12/2012 fail to document any scabbed [MEDICAL CONDITION] to R7's lower extremities or the bruise to her outer right knee. The Treatment Record for 12/2012 has no documentation related to the scabbed areas to the lower extremities or the bruise to the righter outer thigh. The Accident/Incident Log was reviewed for 11/2012 and 12/2012. No documentation related to the bruise or scabbed areas to R7's lower extremities is noted. 6. The MDS dated [DATE], documents R3 requires extensive assistance for bed mobility, transfers, and all activities of daily living (ADL's). During tour of the facility on 12/18/12, at 9:40 AM, with E12, LPN, R3 was asleep in a reclined geriatric chair. Multiple dark purple bruises were noted to the top of R3's hands. E12 reported R3 had a recent fall from a wheelchair. R3 had flaccid paralysis of all extremities and facial muscles and was unable to communicate verbally. On 12/10/12, the Nurses Notes for 12/2012 were reviewed. There was documentation in the Nurses Notes for December related to the current bruising of R3's hands. The Treatment Record for December 2012 was reviewed. There was no documentation in the Treatment Record related to the bruises to R3's hands. On 12/20/12, the facility's Accident/Incident Logs were reviewed for 11/2012 and 12/2012. On 11/01/12, R3 fell forward out of her wheelchair, hit her head and was sent to the local hospital for evaluation. The Admission Nursing History/Assessment, dated 11/06/12, documents R3 was readmitted with purple bruises to both hands with [MEDICAL CONDITION] and bruising around her left orbit (eye area). The physician's orders [REDACTED]. On 12/20/12, at 11:05 AM, E18, LPN was interviewed about the bruising to R3's hands. E18 stated, "I have not noticed them or seen them. I'm not sure with her." E18 did not go examine R3's hands and then wheeled the medication cart into the dining room. 7. The facility Abuse / Neglect Investigation Procedure documented; 1. The staff member who witnesses the suspected abuse will immediately notify the Administrator who will then launch an investigation per self or appointed staff. 4. The investigator will notify the Illinois Dept of Public Health per regulation of the alleged incident. 8. The Resident Census and conditions of Residents, CMS 672, dated 12/19/12 documents that the facility has 73 residents living in the facility. The immediate jeopardy was identified to have begun on 4/30/12 when staff failed to report R2's injury of unknown origin immediately to E1 and the Department, and failed to investigate the injury to rule out abuse. The facility continued to fail to investigate allegations of abuse and injuries of unknown origin, report them immediately to E1 and the Department, and allowed CNA's to have direct contact with residents after potential abuse incidents. On 12/19/12 at 4:45 PM, E1 - Administrator, E2 - Assistant Administrator, E3 -Director of Nursing, E4 - Assistant Director of Nursing were informed of the Immediate Jeopardy. Based on observation, interview and record review, the facility took the following actions to remove the Immediate Jeopardy: 1. The facility will immediately in-service all staff on facility's policies regarding abuse, how to report and investigate incidents. In-servicing stared on December 20, 2012 and completed on 12/21/12. 2. The Director of Nursing and designated licensed staff conducted heat to toe body checks of all residents in facility beginning the evening of 12/20/12 and completing the morning of 12/21/12 with the exception of 10 residents who are alert and oriented and refused the head-to-toe body check. 3. On 12/27/12 a Reporting and Investigation of Incident one page guide was posted at each nurse's station as well as the break room. The form includes the Administrator, Assistant Administrator and Director of Nursing cell/telephone numbers. 4. Verbal interviews with staff regarding abuse policies, who to report abuse to, investigation procedures etc. will be conducted on each staff member at least two times during the next seven days and then intermittently to ensure that all staff know the policies and procedures. 5. On 12/27/12 the facility had reviewed the grievance/concern reporting process with the residents individually and in small group settings, as well as mailed a copy of the grievance/concern reporting policy to the legal guardian/responsible party, or family member. 6. The facility will maintain a log to track, trend and analyze injuries of unknown origin which will be reviewed and discussed by the Quality Assurance Committee. 7. If, after an investigation, abuse has been ruled out, the injures will be referred to the Care Plan Coordinator to implement or amend the Care Plan to reduce the risk of re-injury.

Based on observation, interview and record review the facility failed to identify causative factors contributing to falls, accidents and injuries; failed to implement interventions based on these identified factors; and failed to provide safe transfer techniques to prevent injury for 6 of 8 residents (R1, R2, R3, R4, R7, and R9) reviewed for safety/supervision concerns in the sample of 15. This failure resulted in R3 sustaining a left orbital and maxillary fracture. Findings include: 1. The POS dated 12/2012 documents [DIAGNOSES REDACTED]. The MDS dated [DATE], documents R3 is severely impaired with cognition and decision making, and requires extensive assistance with transfers and bed mobility. The MDS documents R3's balance while standing or seated as unsteady. The Fall Assessment, dated 11/06/12, documents R3 is a high risk for falls. The Incident/Accident Report dated 7/21/12 at 4:30 PM, documents R3's alarm was sounding and she was found sitting on her buttocks in front of her wheelchair without injury. The Investigation of Incident dated 7/21/12, documents R3's roommate reported R3 just slid out of her wheelchair. The interventions documented after the fall are, "Non skid applied to wheelchair cushion (top and bottom) cushion replaced in wheelchair. Staff instructed to keep in supervised area when up in wheelchair." The Incident/Accident Report, dated 11/01/12 at 12:30 PM, documents, in part for R3, "Sitting in wheelchair at nurses station, staff turned away to speak to a family member, turned back around and resident (R3) on the floor face down in front of wheelchair. Unresponsive for a few minutes." An ambulance was called at 12:45 PM, and R3 was sent to the local hospital for evaluation and treatment and was admitted (to the hospital). The Investigation of Incident, dated 11/01/12, documents R3's clip safety alarm was not sounding, and E12, LPN had turned around from the nurses station and got up to go to the supply room. E30, RN was passing medication by the nurses station and was speaking to a family member, turned and noted R3 on the floor. The Investigation documents, in part, R3 "Was sitting in supervised area. Clip alarm must have slid off." No intervention to prevent further falls is documented in the report or investigation of the fall. The hospital's Acute Care Surgery Evaluation, dated 11/02/12, documents, in part, "fall from wheelchair at nursing home, is not accompanied by anyone and is nonverbal at baseline. Injuries to left face. CT (Cat Scan) of maxillary face positive, left orbital floor fracture, maxillary fracture." The Nurses Note, dated 11/06/12, at 12:20 PM, documents, in part, R3 has "2 plus left eye hematoma, laceration above left eye with 2 sutures. No surgery at hospital." On 12/18/12 and 12/19/12, R3 was observed in a reclined geriatric chair. R3 had flaccid paralysis to both upper and lower extremities, no trunk strength and had no verbal communication. R3's Care Plan, dated 11/01/12, documents in part, "I do have a history of falls. I fell in the common area-to ER (emergency room ), hospitalized . 11/06/12 returned with fracture left orbit." Approaches documented do not include the use of a reclined geriatric chair. An Approach documented is, "Observe me in my own environment for possible safety issues. Apply the appropriate precautions, sensor pad and clip alarm in my bed, recliner and wheelchair." Placing R3 in a supervised area is not documented as an intervention to prevent falls. 2. On 12/19/12, a review of R1's incident reports with E3, DON, was done. The reports are from 6/3/12 through 12/18/12 and documented the following injuries; 6/3/12 - While removing a clip alarm from R1's clothing, a skin tear was noted to her left arm. No further documentation of investigation or interventions was found in the report. E3 stated, The alarm was attached to the left sleeve of her gown, and I think R1 rolled on it in bed and cut herself. Staff should have placed it higher up on the gown to keep R1 from rolling on it. The care plan does not have documentation for this event. E2 stated she did not do any retraining on this issue with staff, just told them to watch where they place the alarm clips. 7/24/12 - Resident was being transferred by 2 CNA staff from wheel chair to shower chair. Left leg bumped into side of wheel chair (w/c) causing a 1.2cm by 1cm skin tear. No further documentation of investigation or interventions used was recorded on the report. On 7/25/12 the care plan documents the skin tear and "no new orders". E3 stated that she had read the incident report and if the care plan had no interventions documented then nothing had been done about the skin tear. 8/12/12 - CNA stated she was getting R1 up for the morning, from bed, and noticed a 1cm X 1cm skin tear to the left leg below the knee. The care plan documented 8/13/12, I have skin tear to left outer lower leg. No interventions / preventions documented. E2 stated she had reviewed the report, but no other interventions were initiated. 9/5/12 - Bruises noted by staff to both hands. Neither R1 or staff can say how bruises happened. Has fragile skin and bruises easily. The care plan has no documentation for this incident. E3 stated "if not written on care plan, nothing else was done. 9/26/12 - Bruises found by family on left leg and ankle. The care plan documents 9/26/12, R1 sustained bruises to her left leg and a skin tear to her left arm. No interventions listed for this event. E3, stated she was aware of this report, but did nothing more than read the report. 9/27/12 - R1 sustained a 7.0cm X 3.0cm X 2.0cm elongated, jagged, flapped type skin tear to left arm with bruising. A written statement by E33, CNA, dated 9/27/12, documented that on the evening of 9/26/12, R1 was hanging her legs off of the bed and E33, had repositioned R1 back into bed on at least 2 occasions. E33 and E40, both CNA's, then did peri care on R1 in bed, rolling her back and forth during care, and after completing care, E33 noticed the skin tear on R1's arm. R1's care plan had no documentation for this incident. E3 stated she had reviewed the incident report, and determined the skin tear had probably occurred when staff were moving / providing care to R1. 12/10/12 - Noted to have a 5.0cm X 5.0cm purple bruise to right wrist and 4.5cm X 1cm bruise to left fore arm. No complaints, thin skinned, bruises easily. In a statement by E12, LPN, on 12/10/12, she documented that R1 was being transferred by mechanical lift, and attempted to grab the lift bar and hit her wrist, causing the bruise. E12 also documented that R1's bruise to her left arm was some how due to the strap of the lift, but did not specify how. E3, stated that she had reviewed the incident report, and agreed that R1's bruise to her right wrist was from grabbing at the mechanical lift bar and hitting herself on the bar. E3 stated she thinks the bruise to R1's Left wrist was some how cause because she got her arm pinched in the lift sling as R1 was being raised. The care plan documents this incident, but no interventions to prevent further injury to R1 during mechanical lift use are listed. E3 stated no further interventions were done. 12/18/12 - Son noted skin tear to R1's right elbow while lying in bed. E30, Registered Nurse, (RN) documented that she went to examine R1 in bed, and saw her lying with her arm rolled up in the sheet, and laying against the bed rail. R1 had a 1.5cm skin tear. The care plan documents the incident on 12/18 and treatment orders to clean and cover. No other preventions are listed. On 12/19/12, in an interview with E3 stated that she was aware of all of the above incidents and had reviewed all of the reports. E1 stated that she had not realized that many of them had occurred when staff were caring for R1. E3, stated that although she had told staff generally to be careful with R1, she had not done any specific training or discussed further interventions with staff regarding prevention of further injuries to R1. E3 stated if it is not in the care plan, nothing more was done. E3 stated she is currently reviewing the 12/18/12 incident / skin tear of R1's elbow, but has not completed her investigation or decided upon an appropriate intervention as yet. 3. A review of the POS dated 12/1/12 for R4, documented [DIAGNOSES REDACTED]. The recent MDS dated [DATE], documented R4 was severely cognitively impaired. The most recent care plan dated 9/6/12, documented R4 "has short term memory deficits. I am told things but do not remember, at times I do not even know where I am." A review of an incident report written by E3, DON on 10/2/12, documents; R4 was in restroom, states she fell forward and hit her face on the rack on the wall. 3 inch laceration to forehead, skin tear to nose, hematoma on right cheek. Sent to hospital for evaluation. R4 was trying to take herself to the rest room without assistance. Alarm was attached to chair, but not sounding. A review of R4's care plan dated 9/15/12 documented the fall on 10/2, and that R4 had stitches and a dressing. Additionally the care plan included but was not limited to: I fell at home and fractured my right hip, my family found me sitting on the porch c/o pain and unable to ambulate, I can become confused and not know where I am, I will be free of avoidable falls by next care plan review. Keep call light in reach and remind me to use, staff will assist with mobility, remind me to lock wheel chair when getting up or sitting down. I will be observed in my own environment for possible safety issues. On 12/19/12 at 10:30 AM, in an interview with E3 she stated, "R4 was found on the floor, and her alarm was not sounding. The maintenance director replaced the alarm." E3 stated "R4 does become confused and tries to walk on her own. R4 has poor safety awareness, but at this time R4 had no other measures for supervision to prevent falls other than those listed above in the care plan had been implemented. 4. R9 was admitted to the facility on [DATE]. Her December 2012 physician's orders [REDACTED]. R9's Current Minimum Data Set ((MDS) dated [DATE] assessed her as needing extensive assistance of one staff for bed mobility, limited assistance of one staff for transfer, ambulation, toilet use. Her balance is assessed as unsteady, unable to stabilize herself without staff assistance. Physical Therapy assessment dated [DATE] assessed her with abnormal gait and need to improve strength for transfers and gait. R9 had several incidents of being lowered to the floor while being ambulated by staff. On 5/8/12 at 11:25 AM, she was ambulating with staff to the dining room and her knees buckled. There was no injury noted after this incident. On 7/28/12 at 6:20 AM, R9 was lowered to the floor while being ambulated by a CNA. R9 complained of pain after this incident but x-rays were negative for fracture. R9's Care Plan dated 10/31/12 does document she was admitted following a fall and fracture. The care plan states "I do not always call for assistance when I want to move/transfer myself", I am at risk for falls due to a history of impaired balance, unsteady gait." On 11/21/12 at 8:15 PM, R9 was left unsupervised in the bathroom briefly while the CNA moved clothing off the floor. R9 stood up and fell to the floor, hitting her buttocks and shoulder. On 12/19/12 at 11:25 AM, R9 was observed in the bathroom ambulating with assistance using a wheeled walker. R9 had a large bruise on her left buttock. When asked how she obtained the bruise, R9 stated, "It's probably from when I fell the other day." 5. R2's Cumulative [DIAGNOSES REDACTED]. R2's POS dated 3/2/2010 documented "Motion alarm while in bed to alert staff of res (resident) getting up w/o (without) help. Check placement and function Q (every) shift. Under seat w/c alarm to alert staff of res getting up w/o help. check placement and function Q shift. Clip alarm in w/c and bed to alert staff of res getting up w/o help. (Check) placement and function Q shift." R2's Occurrence Report dated 2/6/12 documented R2 was found on the floor in his room. The Report documented "Heard alarm sounding - ran to room upon entering residents room noted resident on knees on fall-mat pushing magazines into night stand." The Report documented "Resident statement: 'I was trying to get up!'" The Section "Actions Taken" documented his care plan was updated and he had no pain when Range of Motion (ROM) was performed." R2's Care Plan was updated on 2/6/12 and documented the new approach "I need to call when I want things done c (with) my papers. I try to do things myself and end up on the floor." R2's Occurrence Report dated 2/22/12 documented R2 was found lying on the floor on his left side in the hallway. The Section "Actions Taken" documented neuro checks were initiated, care plan updated, head to to toe body check and alert charting was initiated." R2's Care Plan was revised on 2/22/12 and documented "I was resistive to care and my UA Showed 3 + bacteria. MD does not want to treat until final culture received. " R2's Occurrence Report dated 3/5/12 at 6:00 PM documented R2 was found on the floor in his room. The Section "Actions Taken" documented he had no pain when ROM was performed, his care plan was updated, staff conducted a head to toe body check and skin assessment, he was placed into bed, his alarms were applied, and his call light was available. R2's Care Plan was revised and documented "Use call light and ask for assistance." R2's Falls detailed Report dated 3/23/12 documented that at 4:15 AM, R2 was visually observed on the floor and his alarms were sounding. R2's Occurrence Report dated 4/1/12 documented "As I entered the room, resident crawling across floor. Bed alarm & bathroom emergency light on. Seen resident at bathroom trying to pull himself up." The Occurrence Report documented R2's care plan was updated, and he was assisted into his wheelchair and placed at nurse's station. R2's Care Plan was revised and documented "I need to be patient with staff and wait til they answer before I try to do things on my own." After this incident, the facility did not revise the care plan with new interventions to reduce R2's risk of falling. R2's Fall Details Report dated 4/2/12 documented at 5:47 AM, R2 was found sitting on the floor. R2's Occurrence Report dated 4/5/12 documented "I heard alarms coming from his room. Went down saw (R2) sitting on floor mat next to his bed. His back was to the bed." The Occurrence Report documented R2 was assisted by two staff and gait belt back into bed and his care plan was updated. R2's Care Plan was revised and documented "I am stubborn and like to do things on my own like I use to. I don't always call for assistance." After this incident, the facility did not revise the care plan with new interventions to reduce R2's risk of falling. R2's Fall Details Report dated 4/4/12 documented at 12:55 AM, R2 was found kneeling beside his bed with his alarms sounding. The Occurrence Report regarding this incident dated 4/5/12 documented "as I came to res (resident's) doorway I say him kneeling beside the bed." The Occurrence Report documented his care plan was updated, he was assisted back to bed and explained the dangers of getting up without assistance. R2's Care Plan was revised on 4/4/12 and documented "I can get confused and unsure of the day and time." After this incident, the facility did not revise the care plan with new interventions to reduce R2's risk of falling. R2's Fall Details Report dated 5/4/12 documented at 10:00 AM he was found kneeling on both knees beside his bed. The Occurrence Report regarding this incident dated 6/27/12 documented he experienced no pain with ROM was performed and he had pink colored knees. R2's Care Plan was revised on 5/4/12 and documented "Observe d/t (due to) found kneeling on floor." The facility's revised care plan did not address new interventions to reduce R2's risk of falling. R2's Fall Details Report dated 5/6/12 documented at 1:50 PM, he was found kneeling on his knees trying to tune the radio. The Occurrence Report regarding this incident documented "Alarms sounding upon entering room found resident on knees beside chair turning radio, assisted to standing position with two and gait belt and transferred back to bed." The Report documented R2 complained of no pain on ROM and had no reddened noted to knees. R2's Care Plan was not revised after this incident. R2's Fall Details Report dated 5/15/12 at 2150 (9:50 PM), documented "bed sensor alarm sounding et (and) was called to res room by CNA. Res in R (Right) hip in front of toilet in bathroom . w/c (wheelchair) was on the other side of room. Clip alarm was on bed - fully intact. motion sensor did not sound until (staff) stood in front of it." The Report documented R2 complained of no pain with ROM was performed, a head to toe body check, alarm applied and was placed into bed. R2's Care Plan was revised on 5/15/12 and documented "I wanted to wash my face (and) ended up on the floor." The facility's revised care plan did not address new interventions to reduce R2's risk of falling. R2's Incident Accident Report dated 5/19/12 at 1:50 PM documented "Resident semi sitting in room beside bed. Staff alerted by call bell alarm. No injuries noted." The Additional comments and / or steps taken to prevent recurrence stated "Has been reminded numerous times not to transfer self." The Investigation of Incident documented "Had been instructed by nurse to remain in bed p (after) catheterization until CNA would be there. Chose to ignore warning." R2's Care Plan dated 5/19/12 documented "I am very stubborn at times. Nurse asked me to wait for CNA to transfer to w/c." The facility's revised care plan did not implement new interventions to reduce R2's risk of falling R2's Incident Accident Report dated 5/26/12 documented "Alarm sounding - when checked res noted to be sitting on buttocks on the mat next to bed." The Comment Section documented "Res (Resident) encouraged to use call light for assistance." The Investigation of Incident form documented "Res instructed numerous times not to self transfers but does on occasion. R2's Care Plan was updated on 5/26/12 and documented "I wanted to go to the bathroom." The facility's revised care plan did not implement new interventions to reduce R2's risk of falling. R2's Incident Accident Report dated 6/24/12, he was found on the floor in his room and alarms were sounding. R2's Care Plan was updated on 6/24/12 and documented "I was confused and restless and unable to explain what happened." The facility's revised care plan did not implement any new interventions to reduce R2's risk of falling. R2's Incident/Accident Report dated 6/29/12 documented at 6:15 AM "Resident was gotten up for AM, then was left in room to brush his teeth, next thing alarms was sounding. Found resident next to bed on knees, too far of a distant from room to nurses station to prevent from happening." The Investigation of Incident form dated 6/29/12 documented "Informed all staff, that he is not be left in room by self." R2's Care Plan revised on 6/29/12 documented "I was confused/disoriented and unable to make comment regarding incident." The facility's revised care plan did not implement any new interventions to reduce R2's risk of falling. R2's Incident/Accident Report dated 8/16/12 documented at 6:20 AM," found resident in his bathroom on his knees in front of his toilet, ROM WNL (Within normal limits)" The Additional comments section documented "Instructed s staff - Do not leave in room by self when awake" The Investigation Of Incident form dated 8/16/12 documented "was just sleeping around 15 minutes prior to incident. All alarms sounded at the same time, except motion alarm did not sound - was sounding properly before that. May have crawled out of bed - under sensor/motion detector to bathroom on his knees- then was able to get up per self to set on toilet." R2's Care Plan was updated on 8/16/12 and documented "I like to do things on my own like I use to but I am physically unable to do anymore. I have BPH (and) sometimes have an urgency to go to the bathroom. I get embarrassed if I become wet so continue to remind me to ask for help." The facility's revised care plan did not implement any new interventions to reduce R2's risk of falling. R2's Incident Accident Report dated 11/1/12 documented at 8:30 PM "Res found laying on his L (Left) side on the floor. The Investigation of Incident documented the alarms were present and sounding at the time of the incident. R2's Care Plan was not revised with any new interventions to prevent him from future falls. On 12/21/2012 at 9:00 AM, an interview was conducted with E7, Care Plan Coordinator. E7 stated the facility utilizes different types of alarms to alert staff R2 is getting up. E7 stated R2 akinesia (loss of control of voluntary muscle movement) is worsening and most of his falls are in his room. A E7 stated the facility has tried a low bed, a bed-side mat on the floor and moving his bedside table. E7 stated in addition they have tried to re-educate him on asking for staff assistance which has been unsuccessful. 6. R1's physician's orders [REDACTED]. R1's Minimum Data Set, (MDS), dated 10/31/12 documented R1 was severely cognitively impaired, and was an assist of 2 staff for all mobility and hygiene needs. A review of an incident report written by E18, Licensed Practical Nurse (LPN) and dated 10/27/12 at 14:45 (2:45 PM), documented that R1 was found on the floor in front of her recliner on her left side. The electric recliner was in a straight up position, and R1 had access to the control of the recliner. R1 was complaining of pain in her left shoulder, hip, and ankle. R1 stated "I slid out of my chair." The report documents that R1's physician was called and ordered X-Rays which documented a fracture of her left hip. The report documented that on 10/27/12, E19 and E39 both Certified Nurses Aides, (CNA's) had toileted R1 at 1:00 PM and placed R1 in the recliner in the reclined position with the control in the pocket on the right side of the chair. At 1:45 PM, R1 was still asleep in the recliner. The report documented that R1 found the recliner control and raised the chair too high, causing her to slide out onto the floor. A review of the MDS dated [DATE], documented R1 was severely cognitively impaired, a BIMS score of 5 and did not walk. The care plan dated 5/30/12 documented an entry in the Fall category on 5/30/12, which read "I am more disoriented than I was in the past". Fall interventions were documented and included but not limited to; Staff will assist with mobility and ADL's, (activities of daily living). Observe me in my own environment for possible safety issues. Apply appropriate precautions. On 12/19/12 at 1:30 PM, in an interview with E3, Director of Nursing she stated, that R1 had gotten the control out of the pocket of the chair on her own. R1 had poor cognition, was forgetful and very confused, and may not have been able to understand that she was raising the chair too high, or realize how to take her finger off the chair control. E3 stated that staff did not think to unplug the recliner to prevent R1 from falling until after R1 fell and fractured her hip on 10/27/12. 7. The POS for R7 in December 2012 documents diagnoses, in part, of Alzheimer's Dementia and Stroke Syndrome. The MDS, dated [DATE], documents R7 is moderately impaired with cognition, does not ambulate and requires extensive assistance with transfers and bed mobility. The Fall Assessment, dated 4/20/12 documents R7 is a high risk for falls. On 12/18/12 at 9:40 AM, R7 was laying on her back in a low bed with fall mats next to her bed. Two half siderails were in the center of her bed. R7 had several scabs areas to her lower extremities and a bruise to her right outer knee. R7 had her legs flexed with her feet flat on the mattress. R7 repeatedly moved her legs to the left, then to the right touching her knees to each siderail. R7 was wearing geriatric sleeves to both forearms. On 12/18/12 at 11:17 AM, Z1 family member was interviewed related to R7's fall of 6/19/12. Z1 stated, "She's had one fall since she's been here. She had a personal body alarm on. She leaned over and fell out of her wheelchair." A non-skid rubber pad was resting on a pressure relieving cushion in her wheelchair. She tries to crawl out of bed at the foot end. She scoots herself down and out of the bed. It was my request to put the siderails in the middle of the bed." The Incident/Accident Report, dated 6/19/12 at 8:30 AM, documents R7 fell forward from her wheelchair while sitting in the hall. R7's personal safety alarm failed to sound. The Report documents R7 suffered a 2 cm (centimeter) X 4 cm hematoma, a 1 cm X 2 cm skin tear to the left hand and a 2 cm X 4 cm abrasion to her left forearm, and was sent to the local hospital for treatment. The Care Plan, updated 11/12/12, documents, in part ""Observe me in my environment for possible safety issues. Apply appropriate precautions." The Care Plan documents the fall of 6/19/12, but no intervention is documented for the fall until 7/03/12; "Utilize full lap tray when up-use only if able to utilize tray. Discontinued on 7/13/12." R7's Care Plan fails to address the use of half siderails in the center of her bed or the non skid rubber pad in her wheelchair. The Siderail Assessment, dated 10/16/12, fails to address the use of the two half siderails in the center of the bed, nor the risk versus the benefits of the use of the siderails. The Nurses Notes for December 2012 fails to address the small bruise to R7's outer right knee. The Treatment Record for 12/12 does not have documentation of the small bruise to R7's outer right knee. The Incident/Accident Report of 6/19/12 and the Nurses Notes for June 2012 do not document the intervention after the fall. The Report fails to document why the personal safety clip alarm was not functioning. The facility's policy and procedure entitled, 'Resident and Staff Safety' documents, in part, for the use of clip safety alarms, "Make sure that the unit is turned on and functioning properly prior to each use (when placing resident in bed or wheelchair and attaching the clip) Check the battery indicator light if the unit has one and change batteries as needed."

Based on observation, record review, and interview, the facility failed to prevent pressure ulcers, failed to turn, reposition, provide pressure-relieving devices, and accurately assess 4 of 5 residents (R12, R7, R9, and R3) residents reviewed for pressure ulcers in the sample of 15. This failure resulted in facility-acquired Stage 3 pressure ulcer on R12's coccyx and two Stage 2 pressure ulcer on R12's buttocks. Findings include: 1. R12 was re-admitted to the facility on [DATE]. Her History and Physical (H & P) dated 10/11/12 from the hospital documented [DIAGNOSES REDACTED]. On re-admission to the facility on [DATE], R12 had no pressure ulcers. Her admission Minimum Data Set ((MDS) dated [DATE] documented no Pressure Ulcers. The facility's Weekly Pressure Ulcer Surveillance Report dated 10/31/12 documented no pressure ulcers for R12. On the 11/7/12 Weekly Pressure Ulcer Report, R12 had 2 pressure ulcers documented. The Report documented the ulcers as "nosocomial" (acquired in the facility). One pressure ulcer on the left buttock was described as Stage II, measuring 1 cm (centimeter) x 0.8 cm x 0.2 cm with a red center. The other pressure ulcer is described as Stage III, measuring 6.5 cm x 0.3 cm x 0.3 cm with red and yellow center. The facility's current report dated 12/6/12 documented the left buttock has a Stage II, 1.1 cm x 0.5 cm x 0.2 cm, status is "deteriorated". The coccyx is described as Stage III, 1.1 x 0.5 cm x 0.2, "deteriorated." On 12/21/12 at 10:12 AM, E16, RN (Registered Nurse), cleaned both wounds with normal saline. She applied a protective ointment to the buttock/coccyx area. A new area was noted on the right buttock. E16 stated, "That new Stage II on her right buttock was discovered on Wednesday (12/19/12)". On 12/21/12 at 10:30 AM, E3, Director of Nursing, (DON) stated, "She (R12) is a high risk for pressure ulcers. She has chronic stasis ulcers on her legs, poor circulation, very low hematocrit and hemoglobin. She had to have 2 units of blood on Tuesday." R12's Braden Scale dated 11/8/12 assessed her at a score of 12 which is high risk for pressure ulcer formation. Care Assessment Analysis summary dated 10/24/12 and Care Plan identified problem of potential for skin breakdown. 2. On 12/18/12 at 12:15 PM, R9 was seated in her recliner with her feet elevated on the footrest of the recliner. At 1:30 PM, E19 and E20, Certified Nursing Assistants. (CNA) assisted R9 in a transfer to her bed. E19 lifted R9's feet into the bed and removed her slippers and socks. R9's feet were both swollen. There was a dark, discolored area and redness noted on R9's right lateral ankle that blanched with pressure. R9 had redness on her right medial heel. On 12/18/12 at 1:45 PM, E16, RN, stated, "Her legs are not usually that swollen. Z2 (Physician), was here today and looked at her. He ordered a Doppler for her today to check the circulation in her legs." On 12/19/12 at 9:15 AM, E16 examined R9's right lateral ankle. The swelling had improved but the area to the right lateral ankle remained a dark discolored area, resembling a deep tissue injury. R9 was seated in a recliner with the footrest up. The frame of the footrest was a hard metal with sparse padding that corresponded to the area on R9's lateral ankle when her feet rested on the footrest was elevated. E16 did not identify the area as a potential deep tissue injury, did not measure the area on R9's right lateral ankle. R9 remained seated in the recliner with her feet elevated at 9:35 AM, 10:15 AM, 10:30 AM, 10:50:AM, 11:10AM, and 11:15AM. At 11:25 AM, E19 assisted R9 to ambulate to the bathroom using a wheeled walker. R9's Braden Scale dated 12/17/12 assessed R9 as a low risk for development of pressure ulcers with a score of 21 (Score of 12 or less represents high risk.) POLICY PROTOCOL: The facility's Pressure Ulcer Prevention Protocol dated May 1992 stated (in part) that resident admitted or readmitted is to have a thorough skin check, any red/open areas measured and documented. "The skin will also be assessed for any pre-existing signs of deep tissue injury, such as a purple or very dark area that is surrounded by redness, [MEDICAL CONDITION], or induration." Residents at risk will have individual care plan developed......Interventions could include.....individualized repositioning schedule, nutritional supplements, resident choices, special support surfaces....Residents will be monitored ...... daily report.....care plans will be modified to reflect current status. 3. The MDS, dated [DATE], documents R3 is severely impaired with cognition, requires extensive assistance for bed mobility, transfers, all activities of daily living (ADL's) and is incontinent of bowel and bladder. The Braden Scale, dated 11/27/12, documents R3 is a moderate risk for the development of pressure ulcers. On 12/18/12, at 9:40 AM, 11:20 AM, 11:47 AM, 12:15 PM, 12:23 PM, 12:30 PM, and 12:45 PM R3 remained laying on her back in a reclined geriatric chair without repositioning. At 12:50 PM, E10 and E11, Certified Nurses Aides (CNA) transferred R3 to bed. R3's pants and incontinent brief were heavily soiled with urine and feces. After incontinent care ws completed by E10 and E11, R3's rectal area was red. R3's left buttock was red, but blanchable. No barrier cream was applied to R3's perineal area. E11 stated, "That's the nurses job." R3 has flaccid paralysis to all extremities except for involuntary movements of her feet, flexing and extending repeatedly. On 12/19/12, at 8:55 AM, R3 was positioned on her back in a reclined geriatric chair. R3's heels were resting directly on the foot rest of the chair. R3 remained in the same position without repositioning at 9:10 AM, 9:25 AM, 10:00 AM, 10:25 AM, and 11:20 AM. On 12/19/12, at 11:40 AM, R3 was wheeled into the dining room, awaiting lunch service. R3 remained in the dining room in the same position until 12:45 PM when E21, CNA assisted R3 to bed. On 12/19/12, at 12:50 PM, E21 was interviewed. E3 confirmed R3 had not been repositioned, and stated "You've been up too long." R3 had fecal smears on her incontinent brief. R3 had no barrier cream on her perineal area. R3's left heel had a large red area, but blanchable. R3 had a scabbed, Stage II area to her right inner buttock with surrounding [DIAGNOSES REDACTED] (redness). R3's Care Plan, dated 11/06/12, documents R3 had a previous history of a Stage III pressure ulcer to buttocks in January of 2012. Approaches documented on R3's Care Plan do not address a turning and repositioning schedule or other pressure relieving interventions for her buttocks or heels. The Care Plan documents, in part, "(barrier cream) to buttock TID (three times daily) and PRN (as needed). Clean with soap and water." The Treatment Record for December 2012, documents R3 has on 12/12/12, "coccyx- mild redness to buttocks. Free of breakdown", and on 12/19/12, "Mild redness to coccyx and buttocks." The facility's policy and procedure, entitled 'Pressure Ulcer Prevention Protocol' documents, in part, "Residents who are considered at risk will have an individual care plan developed upon admission to remove/reduce those risk factors. Interventions could include, but not limited to, individualized repositioning schedule, nutritional supplements, resident choices, special support surfaces. If a resident is incontinent or skin is exposed to excessive moisture, routine pericare should be performed as per facility protocol, underpads or briefs can be used, periguard or other barrier cream should be applied." 4. The MDS, dated [DATE], documents R7 is moderately impaired with cognition, requires extensive assistance with transfers, bed mobility and personal hygiene, and is incontinent of bowel and bladder. On 12/18/12 at 9:40 AM, 11:17 AM, 11:45 AM, and 11:58 AM, R7 remained in bed positioned on her back. On 12/18/12, at 12:00 PM, E10, E28 and E29, CNA's provided incontinent care for R7, briefly turning R7 from side to side. R7 had been incontinent of urine and feces. No redness or open areas were noted to R7's perineal area. No barrier cream was applied to R7's buttocks. At 12:10 PM, R7 was again positioned on her back. R7 remained positioned on her back, asleep at 12:50 PM, 1:10 PM, and 1:55 PM. At 2:40 PM, R7 was positioned slightly to her left side. R7 was extremely thin and emaciated. On 12/19/12, at 8:55 AM, 9:22 AM, 10:00 AM, 10:25 AM, and 10:47 AM R7 was laying in bed on her back. On 12/19/12,at 10:55 AM, a skin check was performed with E13, Licensed Practical Nurse (LPN). A nonblanchable [DIAGNOSES REDACTED] (redness) Stage I pressure ulcer to R7's left sacral area was observed. In an interview at that time, E13 reported she was unaware of the area to R7's sacral area. The Monthly Weight Record for 11/2012 documents R7's weight as 98 pounds. R7's Care Plan, updated 11/28/12, documents in part, identifies she is at risk for skin breakdown, with a history of gout to feet, bunion sores, skin tears and rashes. The approaches documented, in part, are "When I am less responsive, be sure my position is changed at times. (Barrier cream) apply to buttocks and coccyx TID" No interventions are documented for a repositioning schedule for R7 for pressure ulcer prevention.

A. Based on record review, observation and interview, the facility failed to use a gait belt for 2 (R2, R15) of 6 residents reviewed for falls. This failure resulted in R2 falling, and sustaining severe bruising and lacerations to the face, arm, and leg. Findings include: 1. R2 was admitted to the facility on [DATE] with diagnoses, in part, of cellulites of legs, diabetes mellitus, obesity, hip fracture and degenerative joint disease. R2 was assessed on the 10/13/10 Minimum Data Set (MDS) as cognitively independent. The MDS documented R2 requires limited assistance of 1 person physical assistance for transfers and ambulation. R2 receives coumadin therapy. According to the " Falls Detail Report " dated 11/7/10, R2 was ambulating to the dining room at 3:55 PM. R2 was walking with her walker and E4, Certified Nurse Aide, CNA, was " walking resident in hallway without gait belt with WC (wheelchair) following when she said she wanted to sit down she leaned back causing her to pitch forward and fall " . R2 sustained 2 abrasions on her left knee, skin tear with surrounding bruising above the left eye and 6 x 9 centimeter hematoma to the left arm at the elbow area. R2 stated on 11/30/10 that she fell while walking with her walker in the hall. R2 was observed with fading bruising to her left forehead and entire side of her face. A healed laceration was observed on the left eyebrow. R2 also had a bandage on her left arm. R2 stated that there was a big blood blister on her arm which popped. R2 stated they were treating the area. R2 stated her head did not hurt anymore. R2 stated that she was taking coumadin, and that is why she bruised so badly. On 12/2/10 R2 stated she did not have a gait belt on when she fell . R2 stated that sometimes they used one, and other times they didn't. R2 stated "Now they do." R2 stated it doesn't bother her to have a gait belt on, and staff use one all the time now. R2 stated she didn't think it would have helped to keep her from falling as she is " too heavy " . E1, Assistant Administrator, stated on 12/2/10 that R2 doesn't like to use the gait belt and has the right to refuse. E1 confirmed that there was no gait belt on R2 at the time of the fall. E1 confirmed that E4 was disciplined due to the fall. E1 confirmed that there was nothing on the care plan regarding R2 refusing to wear a gait belt. Review of the care plan dated 8/26/09 through 11/7/10 identified falls as a problem with unsteady balance and gait but able to steady self without physical support. There is no information identified on the care plan regarding refusal of gait belt use. The care plan dated 10/7/10 through 10/13/10 states R2 " requires staff physical assistance (with) ambulation (with) wheeled walker. She is able to ambulate to (and) from bathroom in room (and) ambulates in hallway toward dining area as tolerated. Continue to monitor for unsteadiness of balance (and) gait while ambulating... " . The policy and procedure titled " Safety (Gait) Belt Use " states " All residents who require weight bearing or hands on assistance with transfers and/or ambulation will be transferred and/or ambulated with the use of safety (gait) belt, unless it is medically contraindicated. If it is determined by the care plan team that the resident does not require the use of the safety belt, it will be noted on the resident ' s individualized plan of care ... " . The policy also states " Failure to utilize a safety (gait) belt when assisting a resident to transfer will result in disciplinary action, up to and/or including suspension or termination of employment " . E1 confirmed staff received a written disciplinary action. E4 was unable to be reached for interview. 2. A review of R15's nursing notes dated 6/27/10, 3:45 AM, stated; " Pt was ambulating with wheeled walker to recliner with stand by assistance of E12, CNA. Pt had just used toilet, and was turning to sit down in recliner and fell sideways to floor, falling against dresser." On 12/3/10, in a phone interview, E12 stated; "I did not put a gait belt on R13 because she was a stand by assist. I don't think we have to use gait belt's for those people. On 6/27, when R13 fell , she was turning to sit in her recliner, lost her balance and fell sideways into the dresser. I was afraid if I tried to catch her she or I would get more hurt." A review of R15's care plan indicated she had a history of [REDACTED]. The care plan indicated on 4/19, R13 had fractured her arm during a fall where she had lost her balance. An update to the care plan dated 5/24/10 stated; # 13, " I may become weak with transfers. Make sure you have a safe hold on my gait belt during transfers. Don't use my arms. On 12/3/10 at 10:00 AM, E1 and E2, both Assistant Administrators, indicated they had no further information regarding R13's fall, and why staff failed to use a gait belt and ensure a safe transfer for R13. B. Based on observation, interview, and record review the facility failed to maintain safe hot water temperatures at water fixtures which were accessible to residents in 12 resident rooms, and one (east) of two common restrooms. Findings include: 1. On 12/2/10, at 10:05 AM, in Room 110, the hot water temperature at bathroom sink fixture was taken with a digital thermometer and was 117.8 degrees Fahrenheit (F). 2. On 12/2/10, at 10:13 AM, in Room 123, the hot water temperature at the bathroom sink fixture was 118.8 degrees F. 3. On 12/2/10, at 10:17 AM, in Room 125, the hot water temperature at the bathroom sink fixture was 119.1 degrees F. 4. On 12/2/10, at 10:20 AM, in Room 135, the hot water temperature at the bathroom sink fixture fluctuated between 112 degrees F and 116 degrees F. 5. On 12/2/10, at 10:27 AM, in Room 101, the hot water temperature at the sink fixture in the bathroom was 123.7 degrees F. 6. On 12/2/10, at 10:33 AM, in the unlocked common-use restroom on the East hall, the hot water temperature at the bathroom sink fixture was 123.6 degrees F. 7. On 12/2/10, at 10:36 AM, in Room 202, the hot water temperature at the bathroom sink fixture was 121.2 degrees F. 8. On 12/2/10, at 10:42 AM, in the bathroom between Room 205 and Room 206, the hot water temperature at the sink fixture was 122.2 degrees F. 9. On 12/2/10, at 10:45 AM, in the bathroom between Room 218 and Room 219, the hot water temperature at the sink fixture was 120 degrees F. 10. On 12/2/10, at 10:50 AM, in the bathroom of Room 223, the hot water temperature at the sink fixture was 119 degrees F. 11. On 12/2/10, at 10:54 AM, in the bathroom of Room 209, the hot water temperature at the sink fixture was 117 degrees F. 12. On 12/2/10, at 3:30 PM, E10, Maintenance Supervisor, indicated he monitored water temperatures in the building one time weekly. He indicated he monitored the water temperatures at the nurse's stations, shower rooms and in the residents' room. He was not aware the hot water was at an unsafe temperature. 13. On 12/3/10, at 9:30 AM, E1, Assistant Administrator, provided documented water temperatures. This document indicated at 3:45 PM, the hot water temperature in the East Shower room was 121 degrees F. The hot water temperature in an East Resident Room was 118 degrees F. The hot water temperature in the West Shower room was 118 degrees F. All of these areas were accessible to residents in the facility.